Orthodontic Practice US - March/April 2013 - Vol4.2

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March/April 2013 – Vol 4 No 2

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ORTHODONTICS

The molar to molar corrector

Dr. Rohit C.L. Sachdeva

Upper airway obstruction - poor function becomes poor form Dr. Bradford Edgren

Avoiding employment claims and lawsuits Eilene Verret and Gibson Pratt

Practice profile Dr. Juan-Carlos Quintero

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BioDigital Orthodontics: part 2

• Faster clinical workflow with Ortho template and “Quick Shot” mode • Unprecedented image clarity with ASTRA for 2D images • Automatic positioning for 2D pan

Dr. Bill Dischinger

EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD

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Volume 4 Number 2

Innovation… it’s a beautiful thing!

As a well-known American philosopher by the name of Mark Twain once said, “There are two constants in life: death and taxes!” Without a doubt, in this day and age, Mark Twain’s comments still ring entirely true. However, there is certainly another constant in life that each and every one of us has experienced: change. We are all fortunate enough to be living in an incredibly exciting and fun time in the “technology age.” Innovation in our society is at its all-time greatest and is changing ever so quickly.

So what has the impact of innovation been on our society? To understand this, we need to look no further than a company by the name of Apple Inc. In 2001, Apple first released a little, but now very well-known, device by the name of the iPod®. This product launch was then followed by the iPod® touch, iPhone®, iPad®, and most recently the iPad® mini. These devices have had a significant global impact on everyday living.

They have drastically changed the music industry landscape with how we listen to and purchase music. They have changed how each and every one of us live our daily lives, communicate, and exchange information. They have also transformed Apple Inc. into the highest market capitalization company in history. And this is just one example of one company’s impact with innovation!

Innovation has also had a tremendous impact on our esteemed profession of orthodontics. In the last 15 years alone, we have seen an explosion in clinical advancements with superelastic wires, self-ligating brackets, functional appliances, indirect bonding techniques, lingual orthodontics, and temporary anchorage devices.

Technological advancements in computer hardware have dramatically improved performance, efficiency, and become incredibly cost-efficient where all of us are moving or have moved into the digital orthodontic practice. Practice management, imaging, and online communication software applications have created an incredibly competitive marketplace. Now, it’s not if you’re going to buy a software application, but which one will meet your practice’s specific needs. Social media (Facebook, Twitter, or blogs) has dominated the World Wide Web with everyone from celebrities to grandparents to children who are online and using it. And innovation has now moved orthodontics into the mobile wireless handheld world of apps. How many orthodontic apps are currently available, and how many apps will be developed in the next 5 years? Haven’t we all heard the slogan, “If there is a problem, then there is an app for that”?

And for me personally and most importantly, innovation has transformed our world of orthodontics from the 2D world into the 3D world of orthodontics. We are now diagnosing and treatment planning with 3D imaging for our patients with cone beam computed tomography (CBCT). Invisalign®, SureSmile®, Insignia™, Incognito™, and Harmony have taken our profession to the next level with 3D treatment utilizing intraoral scanning, CBCT, and CAD/CAM for treatment of our patients. The world of 3D printing has made its entry into orthodontics as well. Innovation has forever changed the way we practice and also has changed the expectations of our patients. We are able to provide a higher quality of care to our patients with decreased treatment times and more comfortable and esthetic appliances. Isn’t that something that all of our patients want?

As a result, it is my belief that as specialists in our profession of dentistry, it is our responsibility to embrace all of these new innovations, especially if they provide value and benefits for our patients. Is it a challenge for our profession? Absolutely! It involves hard work, dedication, financial investment, and training of our team. As the late, great former CEO of Apple, Steve Jobs once said, “There are two key secrets to success for any business: 1) The people in business need to have a passion for what they are doing, and 2) The business needs to have an eye for finding talented individuals to become part of the team.” Innovation can create frustrations at times because change can be difficult. However, change is good if there is a good reason to change. Innovation can be incredibly cool and trendy, so let’s have fun, and enjoy whatever it brings us next. It’s a beautiful thing!

Dr. Edward Lin, DDS, MS Specialist in 3D orthodontics Orthodontic Specialists of Green Bay Apple Creek Orthodontics of Appleton (Wisconsin) ELin@osgb.com

Orthodontic practice 1

INTRODUCTION

March/April 2013 - Volume 4 Number 2

TABLE OF CONTENTS Orthodontic concepts

Practice profile Dr. Juan-Carlos Quintero: Aligned with excellence Diversity, adaptability, music, and technology are the secrets to this practice’s success

6

BioDigital Orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: part 2 Dr. Rohit C.L. Sachdeva explores designing customized therapeutics, managing patient care, and evaluating treatment outcome..... 18

Corporate profile PROPEL® Orthodontics PROPEL® Orthodontics, based in Westchester County, New York, is a developer of innovative devices and techniques that aim to revolutionize how teeth are moved in orthodontic treatment

10

Continuing education Complete Clinical Orthodontics:

Case study The molar to molar corrector Dr. Bill Dischinger discusses a case treated with AdvanSync

12

treatment mechanics: part 2 Dr. Antonino Secchi discusses bracket placement, arch coordination, and leveling the occlusal plane in conjunction with the CCO System......................... 28 Upper airway obstruction - poor function becomes poor form Dr. Bradford Edgren explores a condition that can have a profound influence upon the development of the craniofacial process............... 34

2 Orthodontic practice

Volume 4 Number 2

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TABLE OF CONTENTS

Grow your practice with a sound foundation

Industry news

Research

DENTSPLY GAC takes it from the top................................................40

Increasing practice efficiency and profitability using In-Ovation® R

News from PROPEL Orthodontics .....................................................40

Education exploration GCARE webinars: inspiration, exploration, and education: part 3 Interviews by Orthodontic Practice US Managing Editor Mali Schantz-Feld explore how a new webinar program, GAC Clinical Alliance for Research and Education (GCARE), pertains to all stages of the orthodontic community, from residents to practicing orthodontists.................42

self-ligating brackets In their white paper, Dr. Jerry R. Clark and Jack Gebbie address questions about a specific self-ligating bracket system..........................................44 Dental varnishes and their impact on enamel demineralization and bacterial inhibition: an in vitro model Drs. Mary Eve Maestre, Olivier F. Nicolay, Graham Walker, Michael Levi, and George J. Cisneros evaluate the effectiveness of certain fluoride varnishes.......................................50

Product profile

58

Practice management Avoiding employment claims and lawsuits Eilene Verret and Gibson Pratt discuss how to prevent major employee issues ...........................................56 Observations on growing an orthodontic practice: part 2 Chris Bentson continues his discussion on how to grow a practice with a sound foundation................58

AAO preview ..............61 Materials & equipment.......................64

i-CAT® FLX — the latest Cover i-CAT® cone beam scan courtesy of Dr. Bradford Edgren.

4 Orthodontic practice

advancement in Cone Beam 3D For greater flexibility in scanning, planning, and treatment ................48 Volume 4 Number 2

CCO SUMMIT Philadelphia

2013

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Connecting Individuals, Ideas and Inspiration.

The orthodontists of the CCO understand that curiosity can’t be taught, but it can be satisfied. If you’re an orthodontist of unusually high standards, then you’re invited to join us in Philadelphia on the day before the AAO for the inaugural Complete Clinical Orthodontics Summit. The CCO is the only comprehensive system that addresses diagnosis, treatment planning and treatment delivery in a single, inclusive approach. To share in the education, the ideas and the enthusiasm, please reserve your spot by calling 800-645-5530 or visit mygcare.com.

Antonino G. Secchi – USA “CCO, the home base for orthodontic excellence” Ryan Tamburrino – USA “The transverse dimension: Employing CBCT diagnosis and TAD-supported expansion into everyday practice” Jerry Clark – USA “Fantastic Finishing—Making every case the best it can be (Tips and tricks to produce consistently outstanding treatment results)” Raffaele Spena – Italy "Indications, surgical technique and biomechanical management of the patient treated with PFO (Periodontally Facilitated Orthodontics)" Julia Garcia-Baeza – Spain “Orthodontics & Aesthetics: The importance of a multidisciplinary concept” Celestino Nobrega, DDS, DMD, PhD. – Brazil “Torque expression with self-ligating systems: the CCO Bracket design and clinical outcomes”

Seize Your Intellectual Sovereignty

PRACTICE PROFILE

Dr. Juan-Carlos Quintero Aligned with excellence

Team Quintero: Niña, Gloria, Loly, Maggie, Lily, Natalie, Meylin, Osiris, and Grace

What can you tell us about your background?

What training undertaken?

have

you

Son of an ophthalmologist, I come from a pretty diverse cultural background, being raised partially in South America and partially in North America. I quickly learned that the world is a very diverse place, requiring the ability to adapt to changing environments and different ways of living.

I think I am the epitome of the multicultural American citizen in modern U.S. society.

Besides my traditional residency program, I’ve taken The Ron Roth Course, The Andrews course, The Roncone course and most of The Pankey courses in Key Biscayne, Florida. Of course I maintain current ongoing continuing education meetings such as the AAO.

Why did you decide to focus on orthodontics?

Intellectually, it was the most stimulating of the dental specialties for me. I think it was also a personality-driven decision. I love engaging with many different types of people and clinical challenges in a single day. It’s like every patient is his/her own little challenge and television series with a new episode every 6 to 8 weeks. I think every orthodontist can relate to this. The only problem is my gas tank is pretty empty come 6 o’clock.

How long have you been practicing, and what systems do you use?

I graduated from the University of California at San Francisco ortho in 1998 so I’ve been in practice now for about 15 years. I use a combination of many different systems, but mostly the fixed straightwire appliance.

We know appliances don’t move teeth; orthodontists move teeth. Some systems are more efficient than others.

6 Orthodontic practice

am really fortunate. Of course, making a noticeable difference in people’s lives is such an unbelievable honor. Recently, rediscovering orthodontics through the eyes of CBCT (i-CAT®, Imaging Sciences International) is right up there on the list, too. It has allowed me to slow down and really “see” my patients and get to know them better, anatomically and behaviorally.

CBCT has made practicing orthodontics more satisfying because I feel I am helping my patients more as I see more, and know more. My growing interest in airways and airway-driven treatment planning has brought a whole new level of excitement to my job and a more profound service to my patients.

Professionally, what are you most proud of?

Who has inspired you?

My father mostly, and then my orthodontic mentors such as Dr. Ron Roth, Dr. Larry Andrews, and Dr. Ron Roncone.

What is the most satisfying aspect of your practice?

Although it sounds a bit cliché, the personal interactions with patients from all walks of life, especially in a place like Miami. I

There have been many things from publications, lecturing, organized dentistry, and teaching. But most of all, I am proud of my commitment to always do what’s best for my patients, despite challenging forces such as increased competition, managed care, changing trends in the delivery of orthodontics, and corporate entities wanting to intervene in how we treat patients. Most patients aren’t dentists and don’t know any better. I think it is really about always treating patients with dignity and with their best interest in mind.

What do you think is unique about your practice?

I think it’s a very high tech/high touch practice. Technology has always been a Volume 4 Number 2

PRACTICE PROFILE

Maintain an unparalleled commitment to excellence and constant improvement. Our practice motto and our mantra is “Align yourself in excellence.”

big part of my practice. But I have never in my career witnessed such an astounding breakthrough in our field as what we are experiencing now through CBCT technology. As a result, I am treatment planning very differently now. We’ve reverted back to a two-step consult. We have the patient return back for a second treatment conference visit, and our conversions are above 90%. I was taught, and for many years, I treatment planned from the outside in. I looked at the face, the smile, and then slowly worked my way Volume 4 Number 2

inward towards the teeth, gums, bone, etc.

Now, I do the exact opposite: In order, I start with the airway, the paryngeal airspaces, sinuses, TMJs, skeletal relations, alveolus, root health, then move on to the pretty little white things we call “teeth.” This is pretty unique compared to how I used to practice using traditional 2D imaging.

someone asks you to give a presentation or write an article, but there are only so many hours in a day. Running a busy practice, raising a family, teaching, and being involved in the community is a lot of fun but very time consuming.

What has been your biggest challenge?

It’s hard to imagine being anything other than an orthodontist. But I think if I had the talent, I would have become a professional musician or electronic DJ. I love music,

I would say my biggest challenge has been learning to say “no.” It’s an honor when

What would you have become if you had not become a dentist?

Orthodontic practice 7

PRACTICE PROFILE

Dr. Quintero’s family — (Top) wife Tessie, Maya, and Dr. Quintero.

(Bottom left to right) Sebastian and Lucas

it’s actually a big part of our practice, and patients ask me all the time about our music selection, which I carefully select. I particularly like the piano; the only problem is I was never very good at playing it.

What is the future of orthodontics and dentistry?

Of course, computerized dentistry and virtual treatment planning is the trend. The dentist or orthodontist of the future will be the most computer savvy one. As CBCT machines, intraoral scanners, and 3D imaging software continue to evolve, they will replace panos and cephs, impressions, and human errors. Look for continued individual customization of orthodontic delivery systems such as SureSmile™ (OraMetrix) and Insignia™ (Ormco) using accurate root information derived from CBCT and Anatomodels™ (Anatomage).

What are your top tips for maintaining a successful practice?

It’s relatively easy to be successful and make a comfortable living as an orthodontist in due time. But complacency is a dangerous thing. I would say don’t get too comfortable with your success. Maintain 8 Orthodontic practice

an unparalleled commitment to excellence and constant improvement. Our practice motto and our mantra is “Align yourself in excellence.” Offer the best treatment, the best equipment, the best technology, the best staff, the best facility, the best patient experience, and charge for it!

What advice would you give to budding orthodontists?

It’s so hard coming out of school now because of the mountain-size debt most graduates encounter. But be patient, focus on gaining valuable experience first, and a good salary second. Question everything you think you know, and get ready to really learn. Dr. Ron Roth used to tell me, “Don’t focus on the dollar sign.” Dr. Lindsey Pankey used to tell me, “If the money is in your heart, they’ll see it in your eyes.”

My father used to tell me, “If you’re good at what you do, the money will come.” All three were right on target – best advice!

gym, come back, and “juice” using freshly picked produce from my organic vegetable garden to help fuel my 80-patient per day schedule. Weekends, I enjoy nature walks, photography, and an occasional scenic ride through the Everglades with the kids in our new, prized orange Jeep named Orange Steam. OP

TOP 10 FAVORITES: 1. My family 2. My patients 3. InVivoDental from Anatomage 4. AnatoModels from Anatomage 5. I-CAT® 3D cone beam imaging from Imaging Sciences International 6. My music collection 7. My organic vegetable garden 8. Movie nights with my kids

What are your hobbies, and what do you do in your spare time?

Lately, it seems that raising three young, beautiful kids takes every bit of free time and energy. But a perfect weekday for me begins at 4:30 a.m. — I go to the

9. My new orange Jeep Wrangler 10. AirFloss from Phillips/Sonicare

Volume 4 Number 2

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CORPORATE PROFILE

PROPEL® Orthodontics PROPEL® Orthodontics, based in Westchester County, New York, is a developer of innovative devices and techniques that aim to revolutionize how teeth are moved in orthodontic treatment

T

he PROPEL System was designed to address the age-old problem of how to move teeth faster while achieving predictable results. The PROPEL System uses Alveocentesis™, a technique developed by university researchers, to stimulate alveolar bone to remodel faster by creating micro-osteoperforations in the alveolar bone. These microosteoperforations increase cytokine activity and activate a higher number of osteoblasts and osteoclasts to remodel the bone faster. The result is more predictable movements that can reduce treatment time by 60% or more.

PROPEL has been specifically designed to maximize the bone remodeling effects of Alveocentesis and is the only system of its kind to stimulate alveolar bone through a non-surgical approach.

The process is patient-focused, creating ways for orthodontists to give the most efficient care. Patients benefit from quicker treatment time, and doctors benefit from more predictable results and increased productivity by seeing more patients while freeing up chair time. Doctors using the PROPEL System have reported a higher number of referrals, as they become known in their communities as leaders who offer the latest and most innovative treatment options available.

The PROPEL System can be customized to each individual patient’s needs. These include patients with crowding, space closure needs, molar uprighting, rotations, general alignment, and many other conditions. PROPEL can also be used in conjunction with any orthodontic treatment modality including, but not limited to, Invisalign®, SureSmile®, or any bracket system. In fact, Invisalign doctors are reporting excellent results due to PROPEL eliminating the need for refinement as a result of better tracking and predictability.

PROPEL is an easy three-step process that is done in minutes, chair-side.

No referrals outside the office are needed; 10 Orthodontic practice

patients can be treated during their regularly scheduled visit. Compared to other accelerated orthodontic treatments available, PROPEL does not have any patient compliance implications, nor does it involve costly and painful surgeries.

Clinical trials in the U.S. have demonstrated exceptional and consistent results for accelerated tooth movement and predictability. In fact, PROPEL Orthodontics recently concluded a 6-month open label registry clinical trial to mimic the everyday use that clinicians will experience.

The results from participating orthodontists treating over 100 patients with PROPEL demonstrated that treatment times can be reduced by 60% or more in a range of cases. Notable cases included Invisalign treatments in which patients changed clear aligner trays every 10 days versus the standard 14 with no refinements, a preprosthetic space creation for a congenitally missing tooth completed in 6 months, and an adult celebrity patient who was treated with lingual braces in less than 1 year.

PROPEL is made in the USA. Each unit is packaged sterile and is disposable for a single treatment use. Most patients require only one treatment with PROPEL to accelerate their orthodontic process;

and some may require two, with very few requiring more than two PROPEL treatments.

Doctors who are interested in introducing the PROPEL accelerated orthodontic treatment option into their practice are encouraged to call 855-3-PROPEL or log onto www. propelorthodontics.com. On the website, doctors can register for an account to review case studies, treatment guides, videos, and prerecorded webinars.

PROPEL Orthodontics representatives are available throughout the U.S. to conduct in-office Lunch & Learn meetings as well as web-based presentations. In addition, PROPEL Orthodontics welcomes opportunities to present at study clubs and university resident programs. PROPEL Orthodontics is rapidly expanding with many more products in the development stage. OP This information has been provided by PROPEL Orthodontics.

Volume 4 Number 2

MOVE TEETH 50% FASTER SMILES MADE FASTER The PROPEL System takes only minutes to perform and can be used with any Orthodontic system.

The PROPEL System uses AlveocentesisTM, a university research proven treatment which stimulates alveolar bone.

“This technology has proven valuable in my practice to not only achieve faster results, but also increase patient acceptance into starting treatment.”

“I think accelerated tooth movement with alveolar microperforation is the least invasive, most affordable acceleration modality available. .”

Jonathan Nicozisis, DMD - Princeton, NJ

John Pobanz, DDS -South Ogden, UT

JOIN THE PROPEL REVOLUTION AT

www.propelortho.com

CALL: (855) 3-PROPEL 855-377-6735

Smartphone users scan here

CASE STUDY

The molar to molar corrector Dr. Bill Dischinger discusses a case treated with AdvanSync

A

Herbst appliance is widely used in today’s orthodontic treatment to resolve Class II malocclusions, yet they can interfere with fixed appliance treatment since they must be attached to the mandibular first premolars or have a long cantilever arm that prohibits bracket bonding. Market research indicates that more than 50% of orthodontic patients are classified as Class II cases. Yet, the traditional Herbst treatment is unable to correct the A-P relationship of the upper and lower jaw while simultaneously addressing orthodontic issues — which results in extended treatment times in order to first achieve the skeletal correction.

To address this issue, and advance the mandible while performing fixed appliance dental correction, AdvanSync™ (Ormco Corp.), a molar to molar corrector that is approximately 50% smaller than other Class II Herbst alternatives, is used while brackets can be bonded to the maxillary and mandibular arches from second premolar to second premolar. This article details a patient case that illustrates how the low-profile AdvanSync appliance can orthopedically correct a Class II, while simultaneously and effectively facilitating dental movement with orthodontic braces in a more comfortable and time-efficient manner than traditional Herbst therapies.

Diagnosis and treatment planning A 15-year-old female patient, currently bonded with braces, presented with a lingually inclined Class II malocclusion.

From the onset of treatment, the goal was to devise a new treatment course that would effectively upright and broaden her

Dr. Bill Dischinger has lectured both nationally and internationally on a variety of subjects, including functional jaw orthopedics, indirect bonding, and practice management from a team approach. He is also one of 12 certified Damon instructions who have taught and lectured extensively on passive self-ligation with the Damon System. Dr. Dischinger has written several articles and is actively involved in national study clubs that address the latest treatment techniques. He completed his dental training at Oregon Health Services University in 1997 and his orthodontic residence at Tufts University in Boston in 1999. He grew up in Lake Oswego, Oregon, where he has practiced with his father, Dr. Terry Dischinger, since 1999.

12 Orthodontic practice

Transfer records upon arrival in our office

arch while transforming a retrognathic facial profile. In addition, due to the length of time the patient had already been in orthodontic treatment, a short time frame was desired.

The treatment plan involved use of the Damon® System (Ormco Corp.) on the maxillary and mandibular second premolar to second premolar (upper and lower 5-5) and AdvanSync on the first molars. Prior to treatment, the patient was provided with a Dolphin Imaging (Patterson Dental Supply, Inc.) virtual smile morph for a visual of the projected final smile design and profile.

Total treatment time was estimated at 14 months or less.

Treatment progress The existing braces, bonded by a past orthodontist before the patient moved to another state, were removed. The patient was rebonded with Damon System brackets on the upper and lower 5-5. The AdvanSync crowns were fitted on the first molars. The AdvanSync mechanism was attached to the maxillary crown using Ceka bond-dipped screws prior to insertion. The upper and lower 5-5 were bonded.

Following the bonding, the AdvanSync crowns were cemented one at a time.

After the crowns were fully cemented, the maxillary arch was tied together using figureeight lacing with a steel ligarature tie from maxillary first molar to first molar to prevent the AdvanSync appliance from distalizing the maxillary molars. Coupled with the light ligature wire, enough flexibility is generated to allow the arch to broaden while keeping the molars properly positioned. Arch wires were then placed using .014 CuNiTi wires in the maxillary and mandibular arches. The lower wire was annealed and bent up distal to the arch wire tube of the lower crown.

The next step of the initial activation, to transition the patient into a Class I position, was completed with the arm mechanisms.

They were attached to the lower crowns with the Ceka bond-dipped screws.

It was important to check that midlines coincided after the AdvanSync corrector was applied. A significant number of Class II cases exhibit skeletal asymmetry. In this case, the patient’s mandibular midline was centered before beginning treatment.

The second appointment back Volume 4 Number 2

CASE STUDY

Cephalometric tracings

Transfer record upon arrival in our office

Final ceph taken at day of removal of braces at 14 months of treatment in our office

Volume 4 Number 2

Progress ceph on day of AdvanSync removal at 7.5 months of treatment in our office

was 6 weeks after initial placement. The short time between appointments was to advance the patient’s arch wires sooner due to already having been in braces. At this appointment, a .016x.025 NiTi wire with 20 degrees of labial crown torque was placed in the maxillary arch. A .014x.025 CuNiTi was placed in the lower arch. A surgical tie-back hook was crimped on the maxillary wire between the first molar and second premolar. It was tied back to a hook on the molar crown to aid in the prevention of distalizing of the molar. The figure-eight lacing was left in place, and the lower wire was annealed and bent up distal to the arch wire tube of the lower crown.

Six weeks later, the AdvanSync was activated on both sides, placing the patient into a Class III canine relationship. As routinely executed with Herbst patients, the goal was to overcorrect with treatment.

If the patient is End On Class II to begin treatment, he/she is overcorrected into an End On Class III relationship. If the patient is three-fourths cusp or worse Class II, he/she is corrected to a full Class III relationship, with the maxillary canine between the mandibular first and second premolar. Both of these positions place the patient into an underbite relationship.

Orthodontic practice 13

CASE STUDY

Progress Records, 9 weeks post AdvanSync removal, 10 months treatment time in our office

After being in the overcorrected position for 12 weeks, joint films were taken to verify the condyle was centered in the glenoid fossa. At this point, the condyle was not yet centered. The patient’s age (15 years old) may explain why it took longer for the condyle to center. The joint film was repeated 6 weeks later, and the condyle had centered while the Class III dental relationship had been maintained.

The appliance was then removed by cutting the crowns at all four corners on the occlusal surface just over the occlusal table. The mesiobuccal corner was cut all the way down through the gingival edge of the crown. A crown-removing plier was then used to remove the crowns off the molars. The cement was removed with a handpiece, and the wires were sectioned 14 Orthodontic practice

5-5. The molars were not bonded on the same day as the tissue is typically inflamed, and isolation is difficult. The patient returned to the office 1 week later to have the molars bonded, and any other bracket repositions needed were performed during the panoramic radiograph and repositioning appointment. Following this, orthodontic treatment was finished with standard wire sequence.

Treatment result The result after 14 months of treatment — 7 months with the Class II correction appliance — was a smile with proper incisor and canine torque. The Class II correction was accomplished with a structurally enhanced facial profile. Posttreatment records show a significant

improvement in the jaw relationship due to the mandibular correction. Joint films confirm that the condyles were centered in the glenoid fossa, showing the absence of a dual bite. The patient has experienced no post-treatment relapse of the Class II correction.

Discussion The treatment approach executed implements an effective adaptation of a traditional appliance to orthopedically correct Class II patients in treatment times typical of Class I cases. The evolution of fixed functional appliances opens the door for clinicians to correct malocclusions and advance the mandible in less time without sacrificing results while increasing patient comfort.

Volume 4 Number 2

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visualize.

suresmile has made it possible to not only plan specific tooth movements, but to do so in concert with the patient and the overall treatment plan.

Patients can now be more fully engaged in their treatment and understand what we are attempting to accomplish. suresmile is so much more than wires.

simulate.

eric howard 3D imaging allows us to create patient-specific plans with tooth positions determined by supporting bone. The ultimate reward, however, is when you demonstrate with images and metrics that you’ve reached your treatment goal.

design.

randy moles suresmile is not just a better wire nor does it simply offer incremental treatment improvement. suresmile positively affects all aspects of our clinical and practice management: diagnostics, treatment planning, clinical case management, delegation, scheduling, and marketing.

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manish lamichane Designing exceptional smiles‌ that’s what suresmile consistently empowers.

If you would like to learn more, call for a practice consultation:

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Patient after patient.

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CASE STUDY

Final Records, 14 months of treatment in our office, 7.5 months of AdvanSync

For cases of varying degrees of crowding, open coil springs can be used to gain space. Six weeks after the initial placement, the patient is seen back to either reactivate the springs or engage the previously blocked-out teeth if enough space has been gained. For select cases, where molars are tipped or rotated, or instances of early permanent or late mixed dentition in patients without lower second molars, treatment can greatly benefit from AdvanSync’s customizable features that provide added control and precision. This case was completed using the AdvanSync kit, which includes telescoping rods, screws, upper first molar crowns, lower first molar crowns, 1 mm spacers, 2 mm spacers extenders, Allen wrenches .050 (for screws), and an Allen wrench .094 (for extenders). As the appliance is backed by AOA Labs, AdvanSync can be customized 16 Orthodontic practice

to specific preferences and case needs.

It is important to note that when overcorrecting, it’s beneficial to discuss the treatment approach with the patient at the onset to eliminate any surprise with the treatment result. Clinicians, such as Dr. Terry Dischinger, have been overcorrecting in this manner for more than 30 years with zero patients not completely “dropping back.” Research has shown that the mandible relapses 2.4 mm in the primate studies. This relapse back to a Class I relationship typically takes 2 to 4 months.

In the case presented, Class II correction used was Ormco’s AdvanSync appliances. In May 2012, the AdvanSync 2 was released with technology enhancements, such as reinforced spiralock threading, larger eyelets, and advanced metal injection molding, for better performance and more reliability.

Conclusion This new molar to molar corrector allows for more efficient treatment of Class II cases by advancing the mandible in conjunction with bracketed orthodontics. The reduced size compared with traditional Herbst appliances, which can be customized for a clinician’s preferences, has proven to achieve skeletal and dental corrections with increased efficiency and reduce treatment time. AdvanSync should be considered for orthopedic Class II treatment protocols. OP

References 1. McNamara JA Jr., Brudon WL. Orthodontics and Dentofacial Orthopedics. Needham, MA: Needham Press, Inc.; 2001;63-64,81.

Volume 4 Number 2

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ORTHODONTIC CONCEPTS

BioDigital Orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: part 2 Dr. Rohit C.L. Sachdeva explores designing customized therapeutics, managing patient care, and evaluating treatment outcome Introduction A common challenge facing a clinician is her inability to design therapeutics consistent with the planned treatment.1 Often the disintermediation between these two care events prevents the orthodontist from meeting his targeted treatment goal. If it is achieved, it is through a reactive process which, by its very nature, limits the ability of the doctor to provide timely care. The extended length of care often increases the patient’s likelihood of developing gingivitis, white spot lesions, and in some situations, root resorption.2-7 Furthermore, as the care cycle extends, patient-doctor relationships are taxed. From an operational perspective, reactive care often adds to chairside time, frequency of visits, and cost of care.

Reactive care is not conducive to a patient safety or a patient-centered culture.8

The practice of BioDigital Orthodontics is designed to seamlessly integrate Diagnosis (the care plan) and Therapeutics, i.e., DiagnoPeutics within a care environment that actively subscribes to proactive care processes.8 The engine that drives this is SureSmile technology.8 The aim of this paper is to discuss the application of SureSmile technology in conjunction with the principles and techniques developed by me in designing

Rohit C.L. Sachdeva, BDS,M Dent Sc, is the cofounder and Chief Clinical Officer at OraMetrix, Inc. He received his dental degree from the University of Nairobi Kenya in 1978.

He earned his Certificate in Orthodontics and Masters in Dental Science at the University of Connecticut in 1983. Dr. Sachdeva is a Diplomate of the American Board of Orthodontics and is an active member of the American Association Of Orthodontics. He is a Clinical professor at the University of Connecticut and Temple University and the Hokkaido Health Sciences Center Japan. In the past he held faculty positions at the University of Connecticut, Manitoba and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 80 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 160 papers and abstracts to his credit.

18 Orthodontic practice

customized therapeutics, managing patient care, and evaluating treatment outcome.8-11 Patient K.S. discussed in a previous article1 will be used as an example to illustrate this. Additionally, the interaction between the practice and the SureSmile digital laboratory in the production of the virtual therapeutic model, the virtual target setup, and the manufacture of SureSmile precision archwires with robotically assisted technology will be discussed.

Customized SureSmile

therapeutics

with

Generally speaking, there are two distinct therapeutic phases in the practice of BioDigital Orthodontics with SureSmile namely: A) Pre-customized therapeutics (Phase I) B) Customized therapeutics (Phase II) These therapeutic phases, when designed correctly, are seamlessly integrated and provide a continuum of care for a patient with little or no disruptions. For the purposes of this paper, the pre-customized phase of treatment will be briefly discussed, and the focus of the discussion will reside on the customized phase of treatment.

A) Pre-customized therapeutics (Phase I) The pre-customized phase of orthodontic treatment is designed around the strategy of achieving alignment and partial leveling in a controlled and timely manner, and in patients requiring extraction therapy to close as much space as possible, again in a controlled manner prior to entering Phase II. The strategic goals include designing mechanics around minimal tooth movement, reducing, or eliminating iatrogenic tooth displacements. BioTherapeutic strategies developed by me, such as minimally invasive and replacement therapy driven by variable transformation orthodontics, constraint management,

Figure 1: Simulated guided monitoring (SGM) for patient K.S. Intraoral photographs are matched periodically established against the visual milestones. ** The milestones are derived from the Virtual Diagnostic Simulation (VDS). ***Often the patient takes his/her own images and matches these against the visual milestones. Also note, in Phase I, the objective of closing a substantial amount the extraction space was accomplished over a period of 7 months with sliding mechanics

and concurrent mechanics, and the application of consistent force systems, are all applied to optimize treatment.8-12 Care is actively tracked by using Simulation Guided Monitoring (SGM).8-10 This involves using staged visual treatment milestones (Figure 1) designed from the initial Virtual Diagnostic Simulation (VDS) to follow care progress. More importantly, this involves a collaborative effort between both the doctor and the patient to review treatment progress against the visual pretreatment objectives established at the beginning of care. I have also reported using this approach to manage the patient scheduling based upon treatment response (Response Driven Scheduling).8,10,12 I have found that the participation of the patient in his/her personal care is motivating to the patient.

Generally speaking, this phase Volume 4 Number 2

Figures 2A-2D: OraScan™ 2A. Patient being scanned intraorally. The teeth are painted with SureWhite™. B. Note the pattern of the structured white light that is projected on the tooth surface, and C., the captured frame. D. These frames are stitched together and registered in real time to create a three-dimensional image

Figures 3A-3C: Virtual Therapeutic OraScan of patient K.S. The quadrant scans are stitched together to yield complete scans of the individual arches with brackets. A. Upper arch scan. B. Lower arch scan. C. Bite scan

B) Customized therapeutics (Phase II) The goal of Phase II is to proactively design and use fully customized, robotic bent SureSmile precision arch wires to achieve targeted tooth movement.

This is achieved by the practice and the SureSmile digital laboratory working seamlessly together through the entire production phase. The customized phase of treatment at the practice site is conducted both in vivo and virtually through seven distinct steps while the laboratory processes the appropriate models and the SureSmile precision arch wires (Table 1).

The seven steps in managing Phase II at the practice site are described below

Figures 4A-4D: Patient K.S. 4A and 4B shows the set of extraoral, intraoral, and X-ray images that are taken and sent along with the therapeutic OraScan to the SureSmile digital laboratory for processing. C. Electronic bracket library. The miniCLIPPY® bracket (Tomy™ Group, Japan) family is identified in the library to match the brackets bonded on the patient. The SureSmile electronic bracket library is comprised of over 20,000 bracket sets to cater to the varied needs of the orthodontist. If, the brackets are not available, OraMetrix™ will scan any bracket system into the bracket library for use by the orthodontist. D. Tooth chart Volume 4 Number 2

1. Acquiring the therapeutic scan The therapeutic scan is an in vivo 3D scan of the patient with the brackets on.

This scan helps locate the position of the brackets on the teeth. For patient K.S., the scan was taken at 7 months from the start of active treatment after all the space was closed. Generally speaking, the scan is taken at an earlier point in treatment when a couple of millimeters of space remain to be closed. The intraoral image for patient K.S. was taken with the OraScanner (Figure 2A).

This imaging device uses structured white light to capture images of the teeth (Figures 2B and 2C). The frames are stitched into a 3D representation of the dentition in real time (Figure 2D). The procedure for taking this scan involves first removing the arch wires and then painting the teeth with titanium oxide-SureWhite™ (OraMetrix, Inc).

This is done to improve the reflectivity of the translucent surfaces of the teeth, which aids in image capture (Figure 2A). Scans are taken for each quadrant and stitched automatically to generate a whole image (Figures 3A and 3B). A bite scan is also Orthodontic practice 19

ORTHODONTIC CONCEPTS

Table 1: Phase II Practice-Lab activities: Steps in managing the customized phase of treatment at both the practice site and the SureSmile Digital Lab

of treatment lasts between 2 and 6 months, depending upon the treatment goals and severity of the malocclusion.

In some patients, especially nonextraction Class I with mild to moderate crowding, treatment may begin immediately with customized treatment.

In the case of patient K.S., this phase of treatment lasted for 7 months and involved managing space closure post extraction with sliding mechanics. The treatment plan was comprehensively discussed in part 1 of this article.1

ORTHODONTIC CONCEPTS

Figures 5A and 5B: Virtual Therapeutic Model for patient K.S. captured from the OraScan.

This model can be viewed with the gingival tissue on (A) or off (B). Note the brackets are registered on the model. Also, the “straight” arch wire is modeled. All these are modeled as separate objects. Thus they can be viewed as independent components by the doctor

taken so that the upper and lower jaws can be registered by the SureSmile digital laboratory (Figure 3C). Generally, scanning takes between 15 and 30 minutes depending upon the skill of the operator.

The iTero™ (Cadent, Inc.) scanner may also be used to capture this image. Both these scanners are limited to capturing only the crown and gingival anatomy. Also, CBCT images may be used to acquire the therapeutic scan. With this image, both roots and bone can be visualized.

The choice of the imaging technique is driven by the doctor’s preference and the patient’s needs. Extraoral, intraoral photos, and a panorex radiograph of the patient are taken and collated into the SureSmile patient relational database (Figures 4A and 4B). In addition, bracket families used on the patient are identified from the electronic library (Figure 4C). The electronic brackets are registered by the lab on the OraScan image. This way the “true” prescription of the bracket is reflected. Finally, the practice site completes a tooth chart to identify the number of teeth and any anomalies in size and shape of teeth (Figure 4D). This information is helpful to the laboratory in the modeling process. All this data is digitally compiled and sent electronically to the SureSmile digital laboratory via a secure Virtual Private Network (VPN) for processing.

The SureSmile digital laboratory processes the scan to produce the Virtual Therapeutic Model (VTM) [Figure 5]. Also, the laboratory registers the VTM to both the extraoral frontal facial photograph and mid-treatment cephalometric X-ray, if provided (Figures 8A and 8B). The VTM is electronically shipped back to the practice via a VPN within 5 business days (Figure 6).

20 Orthodontic practice

Figure 6: Schematic showing the integrated activities and timelines in managing the virtual patients at both the practice and SureSmile digital laboratory for the production of SureSmile precision arch wires in Phase II

Table 2: Factors considered in the virtual therapeutic model evaluation (SVTME)

2. Evaluating the Virtual Therapeutic Model (VTM) The VTM is primarily used for two purposes.

Firstly, to evaluate treatment progress, and secondly, to develop a prescription for the virtual target setup from which SureSmile precision arch wires are designed.

Therefore, it is important to evaluate the integrity of this model prior to proceeding with the “design” phase of treatment.

This is accomplished by using a checklist available in the software at the practice site (Figure 7A).

In addition to this, I use the VTM to gain a comprehensive understanding of the subtle or “hidden malocclusion” and the various factors that may have affected the nature of tooth displacement to this point in care. This is done in a systematic manner using the Sachdeva Visual Therapeutic Model Evaluation (SVTME) approach (Table 2). Furthermore, the VTM provides a great aid to communicate treatment progress

with the patient and referral source. a) Global and bite registration The first step in SVTME requires understanding of the orientation of the model in free space (global). This is evaluated against the frontal facial photograph and cephalometric X-ray (Figure 8). Incorrect orientation of the model may mislead the doctor in the assessment of canted occlusal planes. In addition, the bite registration is checked against the frontal and buccal intraoral images. Again, an improper bite registration may lead to misdiagnosis, which can affect the virtual setup prescription, the virtual setup design, and the final prescription of the SureSmile precision arch wires. b) Targeted diagnosis

The SVTME method (Figures 9 and 10) provides for a very useful approach Volume 4 Number 2

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ORTHODONTIC CONCEPTS

Figures 7A-7C: A. Checklist for evaluating the Virtual Therapeutic Model (VTM) for patient K.S. B and C. As one goes through the checklist, matched images are displayed for the doctor to evaluate

Figures 8A-8D: A. Evaluation of global position of the VTM against the frontal facial photograph and the (B) lateral cephalogram. C and D. Bite registration of the VTM is validated against the respective intraoral photographs

Table 3: SVTME Matrix demonstrating the range of model registrations that can be performed to. These registrations may be used as communication aids and also to evaluate treatment response and doctor performance

to detect subtle discrepancies in the malocclusion using the following principles: i. Dynamic visualization: It must be noted that the 3D images are displayed on a 2D flat screen.

Therefore, to develop a 3D visual sense of the model, it is imperative that it is viewed from multiple perspectives so that the hidden features are recognized. An example demonstrating the detection of a subtle rotation in patient K.S. is shown in Figure 9. ii. Feature facilitated diagnosis: Because of the artificial lighting and difficulty in sensing 3D morphology on the teeth, it is important to reduce the feature sets to simple points or line-based landmarks for ease of evaluation. This is shown in Figure 9E. iii. Simulation guided diagnosis: It is 22 Orthodontic practice

very difficult to objectively assess measured tooth displacement by clinical inspection. Using simulations to move teeth to a target and acquiring measures about specific points and fixed references provides a reliable method to measure displacement. An example of this is shown in Figures 9F and 9G. c) Comparative and predictive analysis/ communication

In the virtual world, the ability to register different models by best fit registration allows the doctor to evaluate treatment outcomes effectively as well as readily.

Table 3 shows the matrix of the various possibilities of model registration included in the SVTME methodology.

Figure 11A demonstrates the original planned treatment for patient K.S.1 (the Virtual Diagnostic Simulation superimposed on the Virtual

Figures 9A-9G: A. Lower occlusal photograph of patient K.S. Note the rotation on the LR 2 cannot be identified. B. Also, it is not visible on the VTM when visualized from a perspective similar to that of the photograph. C. It is difficult to visualize the rotation on the LR2 with a closeup view D. when the perspective of the VTM is changed (Dynamic Visualization), the ML rotation on the LR2 is seen.

E. By displaying the feature (Feature Facilitated Diagnosis) points (in this situation the incisal edges), the rotation becomes very obvious. F. The magnitude of rotation can be measured by calculating the amount of displacement required to correct the position of the tooth which is G. 14 degrees (Simulation Guided Diagnosis)

Figure 10: SureSmile has many additional tools to aid the orthodontist in diagnosis. A. Features such as the marginal ridges are automatically identified for viewing B. The electronic articulating paper can be used to identify the interarch contact relationships

Diagnostic Model). Progress in care can be evaluated by superimposing the Virtual Diagnostic Model (VDM) to the Virtual Therapeutic Model (VTM).

The VDM to VTM registration finds great use in understanding how well the reactive segments have been managed (Figure 11B). Furthermore, it provides an invaluable visual aid to communicate with the patients and the referring doctor regarding treatment progress.

Displacement values (Figures 11C and 11D) or resolution of the ABO discrepancy index are useful measures to provide a semi-qualitative analysis to assess treatment progress (Figure 11E). The virtual diagnostic simulation (VDS) can also be registered to the VTM, and this is useful to the clinician in assessing how close his initial treatment goals are adhered to during the course of treatment and if any mid-course corrections in Volume 4 Number 2

ORTHODONTIC CONCEPTS treatment objectives are warranted (Figure 12). Additionally, this superimposition provides a reasonable approach for the clinician to measure and assess his personal skills in planning and predicting the target occlusion. d) Constraint recognition Another aspect of SVTME is to recognize the constraints that affect tooth movement. Early detection of constraints or interferences and their removal is important since they commonly impede tooth movement and may also cause deflective contacts that lead to mandibular displacements (Figure 13). Physical constraints may be recognized at three levels: (i) Type I: Tooth-to-tooth constraint Figures 13A-13E show an example of the influence of a Type I constraint in impeding tooth movement. Note that the straight wire in the canine slot has not completely worked out. This is because the opposing tooth is in close proximity to the distal marginal ridge of the canine. This prevents the further eruption of upper canine.

Figures11A-11E: Patient K.S. A. Virtual Diagnostic Model (VDM) versus Virtual Diagnostic Simulation (VDS). B. Virtual Diagnostic Model (VDM) versus Virtual Therapeutic Model (VTS). C. Semi-qualitative measures of the displacement of the molars and incisors derived from best fit superimposition of the respective models. Note these are average displacement values and show that the planned movement in the pre-customized phase of patient K.S were executed close to plan. (E). The ABO discrepancy index (DI) measures for both VDM and VTM in patient K.S. Note the values have declined.This shows how much correction of the malocclusion has been achieved to this point in care

24 Orthodontic practice

Figures 12A-12B: Shows the superimposition of the Virtual Diagnostic Simulation (VDS) versus Virtual Therapeutic Model (VTM). This offers the clinician the ability to evaluate whether the treatment is tracking to plan. It should be noted that VDS is based upon the final target and the VTM is a mid-treatment. So the difference seen in the displacement values B. provides an indication of the remaining tooth movement

Figures 13A and 13B: Show the straight arch wire in the canine region in patient K.S. has not completely worked out. 13C-13E. Note: This is because of the constraints imposed by the close proximity of upper canine to lower premolar.

F. Note: In patient K.S., the bracket-to-tooth collision between the mesiobuccal cusp of the upper molar and the distal wing of the lower molar bracket. G. Shows the exact location of the collision. H. Coronal sectional view through the molars showing the bracket-to-tooth interference

Volume 4 Number 2

(ii) Type II: Bracket-to-tooth constraint Figures 13F-13H show a Type II constraint, i.e., bracket-to-tooth collision in the lower left molar area. This may cause disocclusion and potentially trigger mandibular displacement or increase the risk of bracket failure. (iii) Type III: Bracket wire constraint This is demonstrated by the lower left first molar (Figures 14A-14K). In examining the “deactivation” state of the arch wire, one recognizes that the arch wire has not worked out in the molar area. It is not straight and has a mesiolingual first order deflection (Figures 14A-14C).

In simulating the deactivation of the arch wire to its final resting state, i.e., straight wire, the following is recognized (Figure 14D). Had the arch wire worked out completely, the first molar would have shown excessive mesiobuccal rotation (undesirable) [Figures 14E-14J].

This, in time, would have affected the sagittal buccal relationships of the first molar, making it appear more Class II. Also, at this juncture in treatment, it is important that the clinician ask himself the question, “Why has the arch wire not worked out?” This may be partly answered by simulation of the molar to its final Volume 4 Number 2

position. In patient K.S., it appears that there is no occlusal interference during the rotation of the tooth, and therefore, other reasons need to be explored that may have prevented further movement of the molar (Figure 14J). Other factors may be associated with orthodontic tooth movement stasis of the molar such as: 1. The arch wire may not generate sufficient force levels for tooth movement 2. The arch wire may be deformed 3. There may be significant bracket arch wire slop 4. Tooth movement is time dependent, and insufficient time may have lapsed to observe sufficient movement 5. Bracket arch wire friction

e) Recognizing errors in bracket placement, prescription, and extent of arch wire expression Lastly, the SVTME technique of model evaluation focuses on recognizing errors in bracket placement and prescription using the principles of simulation guided error recognition.

Also, the degree to which an arch wire has expressed itself during in care can be evaluated using this technique.

There are many types of errors that are

Figures 15A-15I: Patient K.S. Type I: Bracket Placement Error (Subtractive). Error in placement of upper second premolar bracket. Note at full expression, the bicuspid falls short of its target position by 1 mm. B. Shows the simulation guided diagnosis being used to assess how far short the bicuspid is from its target position. I. Shows its 1 mm. Initial (E) and simulated target (F) show the correction in the marginal ridge discrepancies as a result of extrusion of the bicuspid. Also, note in H and I, the slight prematurity that may result with the extrusion of the bicuspid

commonly seen as a result of bracket placement and prescription. These have been classified by Dr. Sachdeva.12 Examples of some of these in patient K.S are shown in Figures 15-17. (i) Type I: Bracket placement error (subtractive) Such error is the result of an ill-placed bracket that at full expression falls short of the tooth achieving its target position. An example of this is the upper left second premolar. When viewing the tooth position and the bracket arch wire relationship, the following is recognized. First the premolar has not erupted fully (Figure 15A); this is also verified by assessing the marginal ridge relationships, and secondly, the arch wire relationship to the bracket is completely straight.

This suggests that the straight arch wire has deactivated to its passive state. Thus, it may be deduced that the bracket was placed in error vertically or in the second order (Figures 15C and 15E). This can be further validated by conducting a simulation to extrude the premolar to its target position (Figure 15B).

One may observe that the marginal level has leveled, and a step down bend is required to achieve correction (Figures 15D and 15F).

Orthodontic practice 25

ORTHODONTIC CONCEPTS

Figures 14A-14K: Patient K.S. Type III: Bracket wire constraint. 14A-14C. Shows the lower occlusal, lower arch wire bracket complex and the lower arch wire VTM images. 14D. Is a simulation of the deactivation of the wire in the lower left molar area. 14E-14G. Is a close up view of the lower left first molar, arch wire and the interocclusal contacts. Note that the arch wire hasn’t completely worked out, and there are no hard contacts between opposing teeth. 14H-14J. Shows a close up of the simulation of the arch wire to its full passive state. Note the resulting mesiobuccal rotation of the molar with no interocclusal interferences. 14K. Shows the amount of over rotation that might occur if the arch wire were to fully deactivate

ORTHODONTIC CONCEPTS Also, extrusion of the premolar results in a slight prematurity on its mesial marginal ridge (Figures 15H and 15I). At the time of arch wire insertion, this may be polished. (ii) Type II: Bracket placement error (additive) In this situation, the misplaced bracket at full expression leads to the displacement of a tooth beyond its target position.

This is seen in the lower left incisor incisors. The brackets were misplaced in the second order leading to mesial angulation of the left incisors (Figure 16). (iii) Type III: Bracket prescription error The upper left canine appears to be upright with deficient labial crown torque (Figure 17). On closer examination of the bracket slot, it appears that the torque in the bracket would be inadequate to correct the position of this tooth, even if a full-sized arch wire were used.

Note: Type IV subtractive bracket error type, another bracket error type, is not discussed in this article.13

Conclusions It is quite apparent that a host of factors impact orthodontic tooth movement clinically (biological and patientdriven factors also affect orthodontic outcomes).12 Recognizing these factors at the chairside is an impossible task.

Furthermore, it is not feasible to make a prognostic determination of the effect of these discrepancies with a mental model.

Simulations are required, which provide the benefit of both visualization and the ability

Figures 16A-16B: Patient K.S. Type II: Bracket Placement Error (additive) A. Initial photo and panorex B. Intraoral photo and panorex at time of therapeutic scan error in the second order (angular) bracket position are seen in both the lower left central and lateral incisors

to measure.

In summary, careful evaluation of the VTM using both the checklist and SVTME principles and method aids the orthodontist in making better decisions for designing the prescription for the virtual target setup. Furthermore, the VTM, when used appropriately, can be a great learning aid for both the patient and the doctor. The next article will discuss the design phase of the Virtual Target Setup (VTS), SureSmile virtual precision arch wire, and the clinical management of patient K.S. OP *Condition based clinical pathway guidelines will be discussed in future articles. †CBCT certified machines with SureSmile are Next Generation i-CAT, Classic i-CAT (Imaging Sciences International); Kodak 9500, CS 9300 (CareStream Dental).

Acknowledgements It is with the deepest sense of gratitude that I wish to thank both Takao Kubota, DDS, PhD, and Sharan Aranha, BDS, MPA, for

Figures 17A-17E: Patient K.S. Type III: Bracket Prescription Error. 17A and 17B. Intraoral photo and corresponding VTM note upper left canine appears to be tipped lingually. 17C-17E. Close-up image of upper left canine.

Note: in Figure 17D, the bracket slot is parallel to occlusal plane and demonstrates “zero torque.” Also, note the arch wire in the slot. Figure E appears to be completely passive. These images clearly demonstrate that the bracket prescription is insufficient to provide buccal crown torque

their unconditional and enthusiastic support in the preparation of this manuscript.

Visit Dr. Sachdeva’s blog on http:// drsachdeva-conference.blogspot.com.

All doctors are invited to join the “Improving Orthodontic Care” discussion blog. Please contact improveortho@gmail.com for access information.

References 1. Sachdeva RCL. BioDigital orthodontics 1: Planning care with SureSmile Technology (Part 1). Orthodontic Practice US. 2013;4:1 4(1):18-23.

2. Hollender L, Rönnerman A, Thilander B. Root resorption, marginal bone support and clinical crown length in orthodontically treated patients. Eur J Orthod.

1980;2(4):197-205.

3. Dudic A, Giannopoulou C, Leuzinger M, Kiliaridis S. Detection of apical root resorption after orthodontic treatment by using panoramic radiography and conebeam computed tomography of super-high resolution.

Am J Orthod Dentofacial Orthop. 2009;135(4):434-437.

4. Sergl HG, Klages U, Zentner A. Functional and social discomfort during orthodontic treatment - effects on compliance and prediction of patients’ adaptation by personality variables. Eur J Orthod. 2000;22(3):307315.

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5. Skidmore KJ, Brook KJ, Thomson WM, Harding WJ. Factors influencing treatment time in orthodontic patients. Am J Orthod Dentofacial Orthop.

2006;129(2):230-238.

9. Sachdeva RCL, Bantleon H. Cantilever based orthodontics – biomechanical and clinical considerations. In: Sachdeva RCL. Orthodontics for the next millennium. Glendora, CA: Ormco; 1997.

6. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod. 1982;81(2):93-98.

10. Scholz RP, Sachdeva RC. Interview with an innovator: SureSmile Chief Clinical Officer Rohit CL Sachdeva. Am J Orthod Dentofacial Orthop.

2010;138(2):231.

7. Artun J, Brobakken BO. Prevalence of carious white spots after orthodontic treatment with multibonded appliances. Eur J Orthod. 1986;8(4):229234.

8. Sachdeva RCL. Integrating digital and robot technologies: diagnosis, treatment planning, and therapeutics. In: Graber ML, Vanarsdall RL, Vig KWL, eds. Orthodontics current principles and techniques.

5th ed. Philadelphia, PA: Elsevier; 2012.

11. Sachdeva RCL, Miyazaki S. Biomechanical considerations in the selection of NiTi alloys in orthodontics and variable transformation temperature orthodontics with copper NiTi. In: Sachdeva RCL. Orthodontics for the next millennium. Glendora, CA: Ormco; 1997:227-246.

12. Sachdeva RCL. Typology and management of constraints and errors in orthodontics. In preparation.

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CONTINUING EDUCATION

Complete Clinical Orthodontics: treatment mechanics: part 2 Dr. Antonino Secchi discusses bracket placement, arch coordination, and leveling the occlusal plane in conjunction with the CCO System Introduction In part 1 of this three-article series, we reviewed the core concepts of the Complete Clinical Orthodontics (CCO) system, how we integrated the straightwire appliance (SWA) with self-ligation to improve control and efficiency, and the rationale for the recently developed CCO prescription, as well as the three stages of treatment mechanics. Specifically, we reviewed the goals and objectives of each stage of treatment emphasizing the more appropriate wire sequence to facilitate accomplishing these objectives.

In this article, we will further review some areas that we think are very important in mechanics and that usually require a more in-depth analysis. We will specifically review bracket placement, arch coordination, and leveling the occlusal plane, as well as their effect on the vertical plane. We cannot emphasize enough how important proper bracket placement is for the progress as well as finishing of our cases. Arch coordination and leveling the occlusal plane are two goals to be accomplished at the working stage. Often overlooked, these

Antonino G. Secchi, DMD, MS, is a clinical assistant professor and former clinical director of the Department of Orthodontics at the University of Pennsylvania. Dr. Secchi received his DMD, Certificate in Orthodontics, and a Master of Science Degree in Oral Biology from the University of Pennsylvania. He is a Diplomate of the American Board of Orthodontics and member of the Edward H. Angle Society of Orthodontists. At the University of Pennsylvania, he has developed and implemented courses on Orthodontic Treatment Mechanics, Straight Wire Appliance Systems, and Functional Occlusion in Orthodontics for postdoctoral orthodontic residents. Dr. Secchi wrote the chapter “Contemporary Mechanics Using the Straight Wire Appliance” for the latest edition of the Graber/Vanarsdall/Vig orthodontic textbook. He also received the 2005 David C. Hamilton Orthodontic Research Award from the Pennsylvania Association of Orthodontists (PAO) and the 2010 Outstanding Teacher Award from the Department of Orthodontics of the University of Pennsylvania. Dr. Secchi is the founder of the “Complete Clinical Orthodontics System” (CCO System™), which he teaches to orthodontists throughout the world. He also maintains an active orthodontic practice in Philadelphia and Devon, Pennsylvania.

28 Orthodontic practice

Educational aims and objectives This article aims to continue the discussion of the CCO System and explore mechanics in greater depth, specifically reviewing bracket placement, arch coordination, and leveling the occlusal plane, as well as the effect on the vertical plane.

Expected outcomes Correctly answering the questions on page 38, worth 2 hours of CE, will demonstrate the reader can: • Identify optimal bracket placement.

• Realize the various aspects of arch coordination.

• Recognize the direct relationship between leveling the occlusal plane and vertical problems.

• Discuss how the maxillary and mandibular occlusal planes can be managed to correct open bite as well as deep bite problems.

Figure 1: Diagram with the correct place of the FA point for each tooth in both the maxilla and mandible

Figure 2: Diagram with all FA points connected with a line as if it were a straight arch wire

two concepts have a direct relationship with treatment of vertical problems.1

Optimal bracket placement Assuming we have the right appliance, the next most important factor when working with an SWA is bracket position.

As Andrews described more than 40 years ago, the brackets should be placed at the FA point.2,3 The FA point is the middle of the clinical crown occlusogingivally and mesiodistally, and follows the long axis of the crown for each tooth in the mouth (Figure 1). When all the maxillary and mandibular teeth are perfectly leveled and aligned, the FA points of all the teeth should be aligned and connected through a straight line (Figure 2). It follows that it should be the orthodontist’s goal to place each bracket in agreement with the FA point (Figure 3), so at the end of treatment, all the

Figure 3: Diagram with brackets and tubes placed in agreement with the FA point for each tooth in both the maxilla and mandible

Volume 4 Number 2

Figure 6: Labial and occlusal diagram of an upper first molar with references for ideal bracket placement. Notice that the long axis of the clinical crown for molars is the buccal groove

Figure 7: Labial and occlusal diagram of an upper lateral incisor with the references for ideal bracket placement

Figure 8: Labial and occlusal diagram of an upper premolar with the references for ideal bracket placement

that usually cause more problems for clinicians, which will be based upon the following important concepts:

position, there are a few considerations that will facilitate bracket placement on teeth that usually present challenges for the orthodontist, such as the upper and lower canines, upper and lower molars, and sometimes upper lateral incisors and premolars.

Figures 4A-4B: 4A: Clinical photo of a case just before removing the appliances. Notice the alignment of the appliance as well as the teeth in both the maxilla and the mandible. Each tooth is in the optimal position, brackets and tubes are in agreement with the FA point of each crown, and a straight wire from second molar to second molar is connecting all brackets and tubes. 4B: The same case just after removing the appliance

teeth can be perfectly leveled and aligned with a straight arch wire (Figure 4). Here is where the orthodontist’s understanding and dexterity will be of great value. The final results of techniques requiring wire bending are affected by the quality and precision of each bend; similarly, the precision of bracket placement affects the final outcome when using an SWA. By this logic, you “start to finish” your cases the day you place the brackets! This is why an important percentage of problems that orthodontists experience toward the end of active treatment—such as marginal ridge discrepancies, difficulty correcting rotations, lack of root parallelism, and, ultimately, less than ideal tooth position— are due to incorrect bracket placement.

Because all the brackets are working at the same time through the wire, one misplaced bracket will automatically affect the adjacent brackets. If more than one bracket is misplaced, the problem will increase and become more noticeable as the leveling and alignment progresses.

This issue, if not corrected, can prevent the orthodontist from finishing the case in an optimal and efficient way.

We will focus on describing the teeth Volume 4 Number 2

• We believe that trained clinicians are able to place brackets consistently at the FA point with their own eyes and without any additional aids but their own eyes.

• The use of any gauge as an aid to position the brackets is not necessary. In fact, to use any predetermined height from the incisal edge to locate the brackets may cause problems and literally negates the use of the FA point, which is one of the fundamental concepts of the SWA development. However, it is important to take into account the individual patient’s tooth morphology such as shorter crowns due to excessive gingival tissue, worn teeth, or fractured teeth that eventually will be restored. In some of these situations, bracket placement should be adjusted accordingly, and as a result, the bracket will look either more incisally or gingivally than the apparent middle of the clinical crown on that particular tooth.

Although the FA point and long axis of clinical crowns are key to bracket

• Canines (Figure 5): The long axis of the clinical crown of the upper and lower canines, which is also the most convex part of the labial surface, is located more mesial than the true mesiodistal center of the tooth; therefore, the FA point looks a little bit more mesial than the dead center of the tooth. If you err and place the bracket on the center of the crown mesiodistally, the canine will rotate mesially.

• Molars (Figure 6): The landmark that Andrews used as the long axis of the clinical crown for the molar is the buccal groove. The FA point lies along the buccal groove and midway occlusogingivally. It is important to realize that the center of the tube mesiodistally should be in agreement with the FA point. As some manufacturers have reduced the mesiodistal length of tubes, orthodontists have started Orthodontic practice 29

CONTINUING EDUCATION

Figure 5: Labial and occlusal diagram of a lower canine with the references for ideal bracket placement. Notice that the most prominent part of the labial side of the canine is a little offset to the mesial

CONTINUING EDUCATION

Figure 9: Diagram with the optimal occlusal relationship of posterior and anterior teeth. When in optimal occlusion, there is an overjet of 2-3 mm from second molar to second molar

Figures 10A-10C: 10A: The maxillary molar buccally is inclined producing a premature contact. This can increase the posterior vertical dimension, which could produce an anterior open bite. 10B: Maxillary molar with proper palatal crown torque. 10C: The optimal molar vertical relationship

Figures 11A-11D: 11A-B: Case with an anterior open bite at the beginning of treatment and then after the maxillary and mandibular occlusal planes have been leveled. 11C-D: Case with a deep overbite at the beginning of treatment and then after the maxillary and mandibular occlusal planes have been leveled

positioning tubes too far mesial causing an over rotation of the molars to the distal.

• Upper lateral incisor (Figure 7): After the third molars, upper lateral incisors are the teeth with more problems regarding size and shape. This makes it difficult to determine the long axis of the crown from the buccal. It is wise to use the mirror to look at the lingual surface of the incisor and then extend the long axis of the clinical crown from the lingual to the buccal.

• Premolars (Figure 8): Usually premolars, specifically second premolars, represent a challenge at the time of bonding due to lack of direct vision. Then it is advisable to look with the mirror from the occlusal and the buccal to locate the FA point and the 30 Orthodontic practice

long axis of the clinical crown.

Arch coordination As discussed in part 1 of this series of articles, the maxillary and mandibular arch wires must be coordinated in order to obtain a proper occlusal intercuspation.

In an ideal intercuspation of a Class I, one-tooth to two-teeth occlusal scheme, the palatal cusps of the maxillary molars should intercuspate with the fossae and marginal ridges of mandibular molars, the buccal cusp of the mandibular premolars should intercuspate with the marginal ridges of the maxillary premolars, and the mandibular canines and incisors should intercuspate with marginal ridges of the maxillary canines and incisors. If this

occlusal scheme occurs, it will then provide an overjet of 2 to 3 mm all around the arch from second molar to second molar.

Then, as seen in Figure 9, the maxillary brackets and tubes are 2 to 3 mm more buccal than the mandibular brackets and tubes and therefore, the maxillary arch wire must be 2 to 3 mm wider than the mandibular arch wire. The arch wire coordination is done at the working stage using a .019” x .025” stainless steel (SS) wire. Even if they come preformed, the clinician should not rely on that, and check them before insertion. Another important aspect of arch coordination is the effect that it has on both the vertical and sagittal dimensions.4 The maxillary teeth should be upright and centered in the alveolar/basal bone and coordinated with the mandibular teeth, which should also be upright and centered in the alveolar/basal bone to obtain a proper intercuspation. Often, this is not the case, and we find maxillary molars buccally inclined, also referred as an accentuated Curve of Wilson, which can produce contacts between the palatal cusp of maxillary molars and the inclines of the mandibular molars, also known as “B contacts” (Figure 10). This decreases the overbite and sometimes produces even an open bite (vertical problem), which in turn can produce a downward and backward movement of the mandible (sagittal problem). This phenomenon is due to the lack of palatal crown torque of the maxillary molars. Depending on the amount of palatal crown torque needed for the maxillary molars to level the curve of Wilson, we suggest the following solutions: 1. For minor to moderate problems with torque, use molar tubes with the CCO Rx (-14˚ of palatal crown torque for the upper first molars and -20˚ of palatal crown torque for the upper second molars) and a .019” x .025” SS wire.

2. For severe problems with torque, a transpalatal bar (TPB) is suggested. TPB can effectively deliver palatal crown torque to maxillary molars.

Leveling the occlusal plane Leveling the maxillary and mandibular occlusal planes to make them almost parallel to each other is a treatment goal in our system. Whether the case started with divergent maxillary and mandibular occlusal planes (e.g., open bite cases) or with convergent maxillary and mandibular Volume 4 Number 2

Composite 1: Initial intraoral photos

Composite 2: Beginning of stage 1, leveling and aligning stage. Upper and lower .014” Sentalloy wires

Composite 2: Beginning of stage 1, leveling and aligning stage. Upper and lower .014” Sentalloy wires

Composite 3: At the end of stage 2, working stage. Upper and lower .019” x .025” SS. Arches are coordinated and maxillary and mandibular occlusal planes are leveled and parallel

Composite 3: At the end of stage 2, working stage. Upper and lower .019” x .025” SS. Arches are coordinated and maxillary and mandibular occlusal planes are leveled and parallel

Composite 4: Final intraoral photos

Composite 4: Final intraoral photos

Composite 5: 1 year post-treatment

Composite 5: 1.5 years post-treatment 42-year-old Caucasian female consulted for orthodontic treatment and was referred by her general dentist due to an open bite. Patient presented with congenitally missing lower second premolars, anterior open bite (only contacting on second molars), small lateral incisors, and history of temporomandibular disorder. She had been wearing a maxillary splint for the last 8 months. At the time of the consultation, she was asymptomatic

occlusal planes (e.g., deep bite cases), at the end of treatment, both the maxillary and mandibular occlusal planes should be level (Figure 11). It is very important to realize the direct relationship between leveling the occlusal plane and vertical problems. We will explain how the maxillary and mandibular occlual planes can be managed to correct open bite as well as deep bite problems.

Vertical problems: open bites To apply the most efficient treatment mechanics, it is very important to understand the cause of the problem; in other words, a proper diagnosis is required!

Some anterior open bites are the result of misaligned posterior teeth affecting the proper posterior overbite. If the vertical dimension increases at the molar level, the anterior overbite will be affected. If the posterior overbite is not corrected, it will be very difficult to correct the anterior overbite.

Volume 4 Number 2

23-year-old Caucasian male consulted for orthodontic treatment due to an anterior open bite. Patient presented with a Class I malocclusion with an anterior open bite from first molar to first molar

Case example 1 shows an anterior open bite due to an arch coordination problem.

The maxillary second molars are buccally positioned causing a primary contact that increases the posterior vertical dimension.

We corrected this case by leveling the Curve of Wilson providing proper torque to maxillary molars so the molars’ palatal cusps could seat on the central fossae of the mandibular molars. As the posterior overbite was corrected, the maxillary and mandibular occlusal planes became parallel, and the anterior open bite closed achieving a proper anterior overbite.

Case example 2 shows another anterior open bite. In this case, the problem is the difference between the tipping of the maxillary first and second molars. The maxillary first molars are tipped mesially, leaving the distal cusps hanging down. We corrected this case by leveling both the first and second maxillary molars. We started with two occlusal planes in the maxilla:

one for the second molar and one for the first molar along with the rest of the teeth.

We finished with only one leveled occlusal plane for the maxilla, which was parallel to the mandibular occlusal plane.

It is important to notice that in both of these cases, the second molars were part of the problem as well as the solution.

Therefore, we strongly suggest that second molars should always be included as part of the comprehensive correction.

Although some orthodontists believe that leveling second molars may open the bite, we have seen so only in a few cases and just temporarily. Once the second molars are completely leveled and coordinated, it will actually help in correcting the vertical problem.

Vertical problems: deep bite It is very common to find inadequate torque of maxillary and mandibular anterior teeth in deep bite cases. The long axes of anterior Orthodontic practice 31

CONTINUING EDUCATION

Composite 1: Initial intraoral photos

CONTINUING EDUCATION

Composite 1: Initial intraoral photos

Composite 2: Beginning of stage 1, leveling and aligning stage. Upper .014” Sentalloy wires

Composite 3: At the beginning of stage 2, working stage. Upper and lower .019” x .025” SS. Reverse curve of Spee was added to the lower wire. Short Class II, 6 oz elastics were used

We treated this case by leveling and aligning the maxillary arch first. Once we leveled the maxillary occlusal plane and achieved the proper torque on all four incisors, we started leveling and aligning the lower arch. At the working stage, reverse curve of Spee was added to a .019” x .025” SS arch wire and short Class II elastics were used. It is important to point out that in cases with severe retroclination of maxillary incisors, spaces will appear between all four incisors as these teeth procline buccally. We strongly suggest leaving these spaces until the lower arch has been leveled, and then close all spaces together. With this approach, we do not risk losing torque of the maxillary anterior teeth by closing the spaces too soon.

Post-treatment cephalometric values show the corrected inclination of maxillary and mandibular incisors.

Conclusion Composite 4: At the end of stage 2, working stage. Upper and lower .019” x .025” SS. Spaces are consolidated, arches are coordinated, and maxillary and mandibular occlusal planes are leveled and parallel

Composite 5: Final intraoral photos

Composite 6: 1 year post-treatment

Correct bracket placement will facilitate the flow of the case at each stage of treatment ultimately allowing an optimal finishing. The clinician should know and be familiar with the proper references and tooth landmarks used for correct bracket placement. The time and effort spent on proper bracket placement at the beginning of treatment will definitely pay off during the course of treatment as well as at the end of it. Arch coordination and leveling the occlusal plane are two very important goals to achieve at the working stage. Unfortunately, these goals are often overlooked. Both arch coordination and leveling the occlusal plane also have important implications in the treatment of vertical problems. The treatment of some open bite cases as well as some deep bite cases can be effectively managed by proper arch coordination and leveling the occlusal plane. OP

Composite 7 15-year-old Caucasian male consulted for orthodontic treatment and was referred by his general dentist. Patient presented with a Class II end-on malocclusion with a deep overbite. Upper and lower incisors were severely retroclined

teeth are often excessively vertical over the basal bone. Also, the Curve of Spee is accentuated and, in some cases, severely deep. In this type of malocclusions, it is mandatory to first correct the inclination of maxillary anterior teeth and to create space in the sagittal plane to unravel the mandibular arch and level the Curve of Spee. By leveling the maxillary arch and providing optimal buccal crown torque 32 Orthodontic practice

to all four incisors as well as leveling the mandibular arch and flattening the curve of Spee, we are once again leveling and paralleling the maxillary and mandibular occlusal planes.

Case example 3 shows a Class II end-on, deep bite malocclusion. As one can appreciate from pretreatment cephalometric values, the maxillary and mandibular incisors are severely upright.

References 1. Secchi AG. CCO Manual on Treatment Mechanics. 2nd ed. Islandia, NY: Dentsply/GAC; 2012.

2. Andrews LF. The six keys to normal occlusion.

Am J Orthod. 1972;62:296–309.

3. Andrews LF. The straight-wire appliance, origin, controversy, commentary. J Clin Orthod.

1976;10(2):99–114.

4. Secchi AG, Ayala J. Contemporary treatment mechanics using the straight wire appliance.

In: Graber TM, Vanarsdall RL, Vig K, eds.

Orthodontics: current principles and techniques.

5th ed. St Louis, MO: Mosby; 2011:561-80.

Volume 4 Number 2

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CONTINUING EDUCATION

Upper airway obstruction - poor function becomes poor form Dr. Bradford Edgren explores a condition that can have a profound influence upon the development of the craniofacial process

W

ho could deny the importance of one’s appearance in modern society? Individuals with more pleasing and tempting facial attributes are more readily welcomed than those without.

While genetics are the initial consideration for all craniofacial development and morphology, malocclusions included, chronic environmental conditions, such as upper airway obstruction (UAO), may be erroneously passed off as genetic predisposition, or more simply, as part of the blueprint of growth.1 In other words, the inherited genetic makeup of the individual (i.e., genotype) ultimately determines the eventual features and attributes of said individual (i.e., phenotype).

Upper airway obstruction (UAO) includes any abnormal condition of the nose, mouth, throat, or larynx that interferes with normal respiration. UAO is often the result of soft tissue enlargement (i.e., allergies), enlarged adenoids compared to the available airway, tonsilar hypertrophy, and/ or inadequate nasal airway development.

Research has demonstrated that impaired nasal respiration can have a significant effect upon the normal development of the craniofacial process and dentition/ occlusion.2-6 By the time young, growing patients present themselves for an orthodontic exam, significant alterations in the normal mode of respiration may have already imposed a profound influence upon the development of the craniofacial process.

A child whose chronic upper airway obstruction remains untreated may develop

Bradford Edgren, DDS, MS, earned both his Doctorate of Dental Surgery, as Valedictorian, and his Master of Science in Orthodontics from University of Iowa, College of Dentistry.

He is a Diplomate, American Board of Orthodontics and an affiliate member of the SW Angle Society. Dr. Edgren has presented to numerous groups on the importance of Cephalometrics, CBCT, and Upper Airway Obstruction.

He has been published in AJODO, American Journal of Dentistry, as well as other orthodontic publications.

Dr. Edgren currently has a private practice in Greeley, Colorado.

34 Orthodontic practice

Educational aims and objectives The purpose of this article is to delve into the various aspects of upper airway obstruction and its effect on younger patients.

Expected outcomes Correctly answering the questions on page 38, worth 2 hours of CE, will demonstrate the reader can: • Define upper airway obstruction.

• Identify craniofacial and dental growth abnormalities that are indicative of the condition.

• Realize why early diagnosis/clinical evaluations are essential to proper treatment.

• Recognize the important role that the orthodontist has in the diagnosis and treatment of upper airway obstruction.

Figure 1: Pretreatment panoramic image demonstrating severe crowding and multiple ectopic and impacted teeth

any number of undesirable craniofacial and dental growth abnormalities. These unfavorable growth problems include: constricted nasopharynx and maxillary arch forms, high palatal vaults, larger total and anterior faces, craniocervical extension, forward head posture, more retrognathic mandibles, vertical dysplasias, mandibular prognathism, and facial asymmetries.

Additional studies have indicated that UAO may lead to sleep disorders and obstructive sleep apnea syndrome in children.7-9 Many of these same craniofacial characteristics including forward head posture, craniocervical extension, narrowing of the nasopharynx and oropharynx can be found in adults suffering from obstructed sleep apnea.10-12 Upper airway obstruction and extended craniocervical posture have also been associated with the signs and symptoms related to temporomandibular disorders.13

Early diagnosis is essential to preventing the undesirable effects from upper airway obstruction. Fortunately, the orthodontist is in a unique position to evaluate upper airway obstructions and their affects upon facial and dental development. An orthodontist’s initial exam should not be limited to just the evaluation of the presenting malocclusion, but should also include assessments of the mode of breathing and tonsilar enlargement. These preliminary clinical evaluations can then be followed up with adenoid and inferior turbinate enlargement analyses from lateral and frontal cephalograms.14,15 “Linder-Aronson and Leighton have shown that the lymphoid tissue on the posterior nasopharyngeal wall is thickest at 5 years of age, and subsequently decreases until 10 years of age.”16 Between 10 and 11 years, there is a slight enlargement, after which the decrease continues.16 Research Volume 4 Number 2

CONTINUING EDUCATION

Figure 2: Pretreatment lateral image exhibiting significant adenoid hypertrophy

Figure 3: Pretreatment lateral image

Figure 5: Frontal analysis

Figure 4: Lateral cephalometric analysis

during the late 1970s by Linder-Aronson and Henrickson,17 Handelman and Osborne,18 and by Schulhof19 developed objective methods of evaluating airway obstruction due to adenoid enlargement with lateral cephalograms. More recently, studies are evaluating the patency of the airway with cone beam computed tomography. Some of these studies have suggested that CBCT scans are an effective technique when analyzing airway volumes.20,21 However, other studies still question the dependability and validity of threedimensional scans in airway evaluation.22 Regardless of the type of imaging, whether two- or three- dimensional, clinical and radiographic evidence should be used jointly when screening the patency of the airway in the orthodontic patient.

Absolute indications for tonsillectomy and adenoidectomy include, but are not Volume 4 Number 2

limited to, adenotonsillar hyperplasia with sleep apnea, or abnormal dentofacial growth.

Relative indications for adenotonsillectomy are adenotonsillar hyperplasia with upper airway obstruction, dysphagia, and/or halitosis.23,24 Currently, there has been a significant shift towards upper airway obstruction, away from infection, as a surgical indication for tonsillectomy and/or adenoidectomy.24 So, who else is better qualified to evaluate existing abnormal dentofacial growth, or the potential for divergent dentofacial growth, but an orthodontist?

Even though upper airway obstruction from adenoid enlargement can resolve spontaneously over time, its consequential negative influence during these periods of rapid facial growth can have remarkable and long-lasting ramifications upon a child’s craniofacial growth. Waiting for

Figure 6: Growth Forecast to Maturity without treatment.

Note the significant mandibular growth ultimately resulting in an anterior crossbite without orthodontic treatment

adenoid enlargement to spontaneously resolve on its own may irreversibly affect a child’s craniofacial development during these periods of rapid growth.20 Shouldn’t future, not just current, craniofacial and dental growth be considered, especially if it’s aberrant, when evaluating a patient for adenotonsillectomy?

By age 7, a child’s craniofacial development has already reached 75% of its total growth. By age 12, 90% of the average child’s craniofacial maturation has been realized.25 So, to wait until age 12, when 90% of a dentofacial deformity has already been established before Orthodontic practice 35

CONTINUING EDUCATION

Figure 7: Super imposition of lateral cephalometric analysis and growth prediction demonstrating significant mandibular growth compared to maxillary growth

Figure 8: Post Phase I treatment panoramic image at age 8 years 10 months exhibiting resolution of severe crowding

Figure 10: Post Phase I treatment lateral image

Figure 9: Post Phase I treatment lateral airway image demonstrating improved airway and straightening of the cervical vertebrae

instituting the appropriate treatment, is not consistent with a preventive philosophy.26 Anterior, posterior, and vertical dentofacial discrepancies are all closely linked to growth. Consequently, interceptive and corrective orthodontic measures, as suggested by the American Association of Orthodontists, should be initiated, at the least, by age 7.27 The earlier the reestablishment of normal oropharyngeal function and nasal respiration, the more likely normal dentofacial development will be reinstituted.16,28,29 Oral respiration may persist for a year or more after the airway has been restored while the original chronic 36 Orthodontic practice

mouth-breathing habit is “unlearned.�27 This 6-year, 4-month-old female presented in my office with severe crowding, including impacted maxillary and mandibular canines. The ectopic maxillary first permanent molars were erupting into lingual crossbite (Figure 1).

Clinically, this young patient had enlarged tonsils and was a mouth breather. The lateral cephalogram demonstrated significant adenoid enlargement (Figures 2 and 3). Cephalometric analysis revealed a skeletal lingual crossbite pattern and a severe skeletal Class III malocclusion due to both the maxilla and mandible (Figures 4 and 5). The growth analysis revealed

Figure 11: Post Phase I treatment lateral cephalometric analysis

the potential for excessive mandibular growth (Figures 6 and 7). The patient had a history of dysphagia, odynophagia, and sleep apnea. The patient was referred to an otolaryngologist who subsequently scheduled her for soft tissue ablation of the inferior turbinates and adenotonsillectomy.

The Phase I orthodontic treatment plan included initially banding the upper arch to relieve the severe crowding followed up with rapid maxillary expansion in the future.

The lower arch would be banded during Phase I to gain space for the ectopic mandibular canines.

Following adenotonsillectomy and inferior turbinate ablation, her frequent Volume 4 Number 2

Volume 4 Number 2

Figure 12: Post Phase I treatment frontal cephalometric analysis demonstrating improved skeletal lingual crossbite pattern

References 1. Ricketts RM. Respiratory obstruction syndrome. Am J Orthod. 1968;54(7):883-898.

2. Harvold EP. The role of function in the etiology and treatment of malocclusion. Am J Orthod. 1968;54(12):883898.

3. Harvold EP, Chierici G, Vargervik K. Experiments on the development of dental malocclusion. Am J Orthod.

1972;61(1):38-44.

4. Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. Am J Orthod.

1981;79(4):359-372.

5. Vargervik K, Miller AJ, Chierici G, Harvold E, Tomer BS. Morphologic response to changes in neuromuscular patterns experimentally induced by altered modes of respiration. Am J Orthod. 1984;85(2):115-124.

6. Yamada T, Tanne K, Miyamoto K, Yamauchi K. Influences of nasal respiratory obstruction on craniofacial growth in young Macaca fuscata monkeys. Am J Orthod Dentofac Orthop. 1997;111(1):38-43.

7. Olsen KD, Kern EB, Westbrook PR. Sleep and breathing disturbance secondary to nasal obstruction.

Otolaryngol Head Neck Surg. 1981;89(5):804-810.

8. Oeverland B, Akre H, Skatvedt O. Oral breathing in patients with sleep-related breathing disorders. Acta Otolaryngol. 2002;122(6):651-654.

9. Katyal V, Pamula Y, Martin AJ, Daynes CN, Kennedy JD, Sampson WJ. Craniofacial and upper airway morphology in pediatric sleep-disordered breathing: Systematic review and meta-analysis. Am J Orthod Dentofacial Orthop. 2013;143(1):20-30.

10. Yu X, Fujimoto K, Urushibata K, Matsuzawa Y, Kubo K. Cephalometric analysis in obese and nonobese patients with obstructive sleep apnea syndrome. Chest.

2003;124(1):212-218.

11. Ozbek MM, Miyamoto K, Lowe AA, Fleetham JA. Natural head posture, upper airway morphology and obstructive sleep apnoea severity in adults. Eur J Orthod.

1998;20(2):133–143.

12. Solow B, Greve E. Craniocervical angulation and nasal respiratory resistance. In: McNamara JA Jr., ed.

Naso-respiratory function and craniofacial growth.

Monograph 9, Craniofacial Growth Series. Ann Arbor, MI: Center for Human Growth and Development, University of Michigan; 1979:87–120.

13. Solow B, Sandham A. Cranio-cervical posture: a factor in the development and function of the dentofacial structures. Eur J Orthod. 2002;24(5):447-456.

14. Major MP, Flores-Mir C, Major PW. Assessment of lateral cephalometric diagnosis of adenoid hypertrophy and posterior upper airway obstruction: a systematic review. Am J Orthod Dentofacial Orthop. 2006;130(6):700– 708.

15. Pirilä-Parkkinen K, Löppönen H, Nieminen P, Tolonen U, Pääkkö E, Pirttiniemi P. Validity of upper airway assessment in children: a clinical, cephalometric, and MRI study. Angle Orthod. 2011;81(3):433-439.

16. Linder-Aronson S, Woodside DG, Lundström A. Mandibular growth direction following adenoidectomy. Am J Orthdod. 1986;89(4):273-284.

Figure 13: Post Phase I treatment Growth to Maturity illustrating improved growth forecast. Patient still exhibits strong lower jaw growth without additional orthodontic treatment, however, the patient doesn’t develop an anterior crosbite 17. Linder-Aronson S, Henrikson CO. Radiocephalometric analysis of anteroposterior nasopharyngeal dimensions in 6-to 12-year-old mouth breathers compared with nose breathers. Orl J Otorhinolaryngol Relat Spec.

1973;35(1):19-29.

18. Handelman CS, Osborne G. Growth of the nasopharynx and adenoid development from one to eighteen years. Angle Orthod. 1976;46(3):243-259.

19. Schulhof RJ. Consideration of airway in orthodontics.

J Clin Orthod. 1978;12(6):440-444.

20. Aboudara C, Nielsen I, Huang JC, Maki K, Miller AJ, Hatcher D. Comparison of airway space with conventional lateral headfilms and 3-dimensional reconstruction from cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2009;135(4):468-479.

21. van Vlijmen OJ, Kuijpers MA, Bergé SJ, Schols JG, Maal TJ, Breuning H, Kuijpers-Jagtman AM. Evidence supporting the use of cone-beam computed tomography in orthodontics. J Am Dent Assoc. 2012;143(3):241-252.

22. Alsufyani NA, Flores-Mir C, Major PW. Threedimensional segmentation of the upper airway using cone beam CT: a systematic review. Dentomaxillofac Radiol.

2012;41(4):276-284.

23. Darrow DH, Siemens C. Indications for tonsillectomy and adenoidectomy. Laryngoscope. 2002;112(8, pt 2) (suppl 100):6-10.

24. Erickson BK, Larson DR, St Sauver JL, Meverden RA, Orvidas LJ. Changes in incidence and indications of tonsillectomy and adenotonsillectomy, 1970-2005.

Otolaryngol Head Neck Surg. 2009;140(6):894-901.

25. Meredith HV. Growth in head width during the first twelve years of life. Pediatrics. 1953;12(4):411-429.

26. Rubin RM. The orthodontist’s responsibility in preventing facial deformity. In: McNamara JA Jr., ed.

Naso-respiratory function and craniofacial growth.

Monograph 9, Craniofacial Growth Series. Ann Arbor, MI: Center for Human Growth and Development, University of Michigan; 1979;323-332.

27. Rubin RM: The effects of nasal airway obstruction on facial growth. Presented at the Upper Airway Compromise Dentofacial Development Symposium, Virginia Beach, VA. 1986.

28. Linder-Aronson S. Effects of adenoidectomy on the deviation and facial skeleton over a period of five years.

In: Cook JT, ed. Transactions of the Third International Orthodontic Congress. London: Crosby Lockwood Staples; 1975:85-100.

29. Mahony D, Karsten A, Linder-Aronson S. Effects of adenoidectomy and changed mode of breathing on incisor and molar dentoalveolar heights and anterior face heights.

Aust Orthod J. 2004;20(2):93–98.

30. Miner RM, Al Qabandi S, Rigali PH, Will LA. Conebeam computed tomography transverse analysis. Part 1: Normative data. Am J Orthod Dentofacial Orthop.

2012;142(3):300-307.

31. Flanary VA. Long-term effect of adenotonsillectomy on quality of life in pediatric patients. Laryngoscope.

2003;113(10):1639-1644.

32. Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by preand postoperative polysomnography. Laryngoscope.

2007;117(10):1844-1854.

Orthodontic practice 37

CONTINUING EDUCATION

sore throats, mouth breathing and snoring resolved. The Phase I treatment significantly reduced the dental crowding and resolved the posterior crossbites (Figures 8-13).

The orthodontist is in a distinct position to promote positive airway development by influencing mid-face and maxillary development in those cases where it is deemed deficient. One should note that skeletal lingual crossbite patterns do not always reveal themselves with obvious posterior dental crossbites. It can be challenging to determine the presence of a skeletal lingual crossbite pattern when it appears that there is a normal transverse relationship between the upper and lower jaws without a frontal analysis.

Many patients who appear to have a normal transverse skeletal relationship can have a skeletal lingual crossbite pattern,30 negatively affecting orthodontic treatment outcomes and airway patency. Frontal cephalograms also provide the ability to evaluate the condition of the turbinates.

The orthodontic patients we treat are three-dimensional. The routine use of frontal analyses on orthodontic cases adds that third dimension and can only enhance orthodontic diagnosis and airway evaluation; ultimately enhancing treatment outcomes. This case demonstrates how the appropriate orthodontic treatment, treatment timing, and referrals, based upon proper diagnostics, can improve the orthodontic outcome for the patient.

Orthodontists should always evaluate the potential for abnormal growth. When growth is not taken into account, an orthodontic case treated to proper balance at age 12 can become a failed result at maturity due to abnormal craniofacial growth, which can be directly associated with UAO. Flanary studied the quality of life for children aged 2 through 16 suffering from upper airway obstruction secondary to adenotonsillar hypertrophy (UAO) and obstructive sleep apnea (OSA). The conclusion from this study was that the quality of life for these children does improve after adenotonsillectomy.31 More recent studies on the improvement of the quality of life following adenotonsillectomy have had similar findings.32

The orthodontist is in a unique position to evaluate upper airway obstruction and abnormal craniofacial development. Early diagnosis and appropriate treatment is the key to helping these patients. OP

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Upper airway obstruction - poor function becomes poor form EDGREN

Complete Clinical Orthodontics: treatment mechanics: part 2 SECCHI

1. Upper airway obstruction (UAO) includes any abnormal condition of the nose, mouth, throat, or larynx that interferes with ______. a. normal respiration b. craniofacial development c. the maxillary arch d. head posture

1. Assuming we have the right appliance, the next most important factor when working with an SWA is ________. a. bracket position b. clinician dexterity c. the FA point d. positioning tubes

2. Research has demonstrated that impaired nasal respiration can have a significant effect upon the normal development of the _______. a. palatal vault b. craniofacial process c. dentition/occlusion d. both b and c 3. ___________have also been associated with the signs and symptoms related to temporomandibular disorders. a. Upper airway obstruction b. Extended craniocervical posture c. Constricted nasopharynx d. Both a and b 4. More recently, studies are evaluating the patency of the airway with _________. a. 2D digital radiography b. cone beam computed tomography c. panoramic radiography d. intraoral cameras 5. By age 7, a child’s craniofacial development has already reached _____ of its total growth. a. 25% b. 50% c. 75% d. 87% 6. Oral respiration may persist for _______after the airway has been restored

38 Orthodontic practice

while the original chronic mouth-breathing habit is “unlearned.” a. 1 month b. 4 months c. 6 months d. a year or more 7. The orthodontist is in a distinct position to promote positive airway development by influencing _________ in those cases where it is deemed deficient. a. mid-face b. maxillary development c. craniocervical extension d. both a and b 8. One should note that ________do not always reveal themselves with obvious posterior dental crossbites. a. adenoid enlargement issues b. skeletal lingual crossbite patterns c. dentofacial deformities d. mouth breathers 9. _______ also provide the ability to evaluate the condition of the turbinates. a. Frontal cephalograms b. Panoramic images c. Traditional 2D film X-ray d. Digital photographs 10. When growth is not taken into account, an orthodontic case treated to proper balance at age 12 can become a failed result at maturity due to ________, which can be directly associated with UAO. a. thickening of lymphoid tissue b. abnormal craniofacial growth c. thickening of the nasopharyngeal wall d. tonsilar enlargement

2. As Andrews described more than 40 years ago, the brackets should be placed at the ______. a. incisal edge b. FA point c. palatal cusp d. lingual position 3. However, it is important to take into account the individual patient’s tooth morphology such as shorter crowns due to ___________that eventually will be restored. a. excessive gingival tissue b. worn teeth c. fractured teeth d. all of the above 4. The landmark that Andrews used as the long axis of the clinical crown for the molar is the _____. a. occlusal intercuspation b. fossae c. buccal groove d. marginal ridge 5. After the third molars, upper lateral incisors are the teeth with more problems regarding ______. a. size b. shape c. over rotation d. both a and b

6. For severe problems with torque, _______is suggested. a. a molar tube b. a transpalatal bar c. 019” x .025” stainless steel (SS) wire d. none of the above 7. If the vertical dimension increases at the _______, the anterior overbite will be affected. a. Curve of Spee b. Curve of Wilson c. molar level d. palatal cusp 8. It is important to notice that in both of these cases _____ were part of the problem as well as the solution. a. the second molars b. premolars c. incisors d. lower canines 9. It is very common to find _______of maxillary and mandibular anterior teeth in deep bite cases. a. tipping b. primary contact c. leveling d. inadequate torque 10. Post-treatment cephalometric values show the corrected inclination of ______. a. maxillary incisors b. mandibular incisors c. molars d. both a and b

Volume 4 Number 2

INDUSTRY NEWS

DENTSPLY GAC takes it from the top DENTSPLY GAC announced that the inaugural Complete Clinical Orthodontics Summit will be held in Philadelphia, on May 3, 2013 at the Ben Franklin Institute.

Founded by Dr. Antonino Secchi, the CCO is an intellectual amalgamation of the leading schools of thought in order to achieve a superior clinical endpoint. For more information, visit www.mygcare.com.

OP

News from PROPEL Orthodontics PROPEL® Orthodontics, the developer of innovative orthodontic devices and techniques, which accelerate the rate at which teeth are moved in orthodontic treatment, has concluded a 6-month open label registry clinical trial.

The company notes that the PROPEL System is a simple three-step in-office procedure that uses a university research backed, patented process called Alveocentesis™ to stimulate alveolar bone in patients undergoing orthodontic treatment. Alveocentesis works by causing a significant increase in cytokine activity, in turn leading to faster bone remodeling.

When used in conjunction with any orthodontic treatment modality including, but not limited to, Invisalign®, SureSmile®, brackets & wires, teeth move 60% or more faster.

The results from participating orthodontists treating over 100 patients with PROPEL throughout the U.S. have been exceptional and consistent with the results seen in hundreds of other patients treated in the past 2 years. Predicted treatment times were reduced by 60% or more in a range of cases including spacing, crowding, open bite, cross bite, and more. Notable cases included Invisalign treatments in which patients changed clear aligner trays every 10 days versus the standard 14 days with no refinements, a pre-prosthetic space creation for a congenitally missing tooth completed in 6 months, and an adult celebrity patient who was treated with lingual braces in less than 1 year.

Bryce Way, President and CEO of PROPEL Orthodontics, is pleased to have received exceptional results from the highly anticipated clinical trial. He says, “We are greatly encouraged by the outcome and look forward to continued rapid growth in the orthodontic market.

A new benchmark has been set for accelerated orthodontic treatment, and we are excited to be the leader.”

Orthodontists seeking additional information on PROPEL accelerated orthodontics can visit www.propelorthodontics.com. OP

40 Orthodontic practice

Volume 4 Number 2

…a band cement in name only.

Ultra Band Lok® in Luer Loc Syringe

Ultra Band Lok® in Standard Syringe

Ultra Versatile.

• Bonds to stainless, gold and buccal amalgam • Bite Turbos • Occlusal Buildups • Seal and lock RPE screws

* U.S. Patent 5,846,075

Ultra Strong.

• Bonds chemically to metal • Easy cleanup • Minimal residual adhesive on tooth surface

Ultra Easy.

• No mixing • Fluoride releasing • Available in tooth

shade or high visibility blue shade • Choice of 2 dispensing methods

EDUCATION EXPLORATION

GCARE webinars: inspiration, exploration, and education: part 3 Interviews by Orthodontic Practice US Managing Editor Mali Schantz-Feld explore how a new webinar program, GAC Clinical Alliance for Research and Education (GCARE), pertains to all stages of the orthodontic community, from residents to practicing orthodontists

Dr. Lou Shuman — President, Pride Institute

I

n creating this GCARE series, we evaluated different subjects that would bring important information and education to the orthodontic community. With support from the Pride Institute, this webinar will concentrate on “Social Media: The Rules of Engagement 2013.” I am excited about offering the orthodontic community a trustworthy level of education about social media marketing in a language that we, as practitioners, can better understand. My goal is to create a social media education initiative on multiple platforms to bridge the gap between social media companies and the dental community. Why am I doing this? Social media companies continue to expand their capabilities like bullet trains barreling down the track so fast that they are leaving the orthodontic community behind at the station. The rules of engagement for social media change so fast that my program literally changes every time that it is offered. To keep my program current, sometimes I literally have to print changes that are occurring and read them live.

This information is imperative in the digital world. In my last few presentations, I have asked about 1,000 clinicians in attendance, “Who truly understands the definition of Search Engine Optimization?”

Out of those thousand doctors, about 15 people have raised their hands. And many of the attendees are already working with SEO, social media, and/or web design companies. So the general thought that practitioners communicate to me is, “I don’t know what I need, but I know I need it, so I write a check.” Unfortunately the 42 Orthodontic practice

minute that happens, the relationship starts going south. The practitioner must be aware of what the definition of social media success is. Traditionally, that has been being number one in Google. The problem is that only one doctor can be number one in Google. So the real definition of success is to give the practitioners a level of knowledge, so they can feel confident communicating and interacting with all the online support companies and create mutually agreed upon goals of what the definition of success should be.

It is important to me that the community understands that entering the social media world doesn’t change who we are. That will NEVER happen. We will always be dedicated to improve the quality of life of patients we see, on a one-to-one basis, dedicated to customer service and technical excellence. Social media will not change that, but it will provide us with new and exciting ways to interact and educate.

The days of how we convert a patient into our practice has changed dramatically.

Instead of the relationship beginning when the patient sits in our chair, as a result of social media, it starts much earlier, many times at the first phone call. The prospective patient has already done his/her homework, been to the websites, and learned about possible orthodontic procedures. The importance of training receptionists how to communicate, educate, and convert the online prospective patient is crucial because the conversion process today begins and sometimes unfortunately can end at the front desk rather than in the chair. I explore many other aspects of social media such as: What are patients looking for on your website? What is the most important page on your website?

How do you attract prospective patients to the website?

With awareness of how search

engines work, doctors can take a more empowered role when interacting with the social media companies. Social media no longer just means being on Facebook and having a website. The key is to participate with numerous social media properties and then, in working with social media companies, integrate them to create a more powerful existence online. Recently, Google decided that participation in social media sites and providing fresh content will impact a practice’s Google rankings.

Creating blogs, using YouTube, being on Facebook, LinkedIn, Dotbiz, and Speakerfile, and many more, creates a significant presence for a business. I will touch on these aspects in my webinar.

This webinar will also update attendees on the latest initiatives from Google and Facebook as the war between them rages on. I have had the opportunity to work and spend time with true experts outside of dentistry and attended a high-security social media convention in Washington, D.C. to witness the direction social media giants are taking in 2013 and 2014, and how it will affect us. Google has become one of the most powerful organizations and social channels in the world, and it is already anticipating reaching far more people with its various channels that include Google+ Local, maps, Blogger, and shopping, just to name a few. Adding video expands the reach even more, and based on recognizing the importance of video, Google acquired YouTube to initiate next generation models of social interaction.

In the light of all of this, doctors must all remember that everything created online is a reflection of themselves, their personality, their culture, their brand. Never accept mediocrity. It is OK to say, “No, that is not who I am or the right portrayal of my practice.” Social media website design companies might be experts when Volume 4 Number 2

Volume 4 Number 2

Local, which is critical at this time, to discuss the business side of Facebook, and how video can make an incredible online impact. We have so much information to share to open the door to the consumer community. My focus is to empower my peers and to provide more confidence interacting online.

For future webinars, my goal will be not only to continue to provide the latest information on SEO, social media, and web design, but take on a curator role, introducing the GAC community to experts both in and out of dentistry, to continue the mission to provide the most relevant education destination in orthodontics.

Dr. Richard Cousley—U.K. consultant orthodontist For the GCARE series, I am planning a succession of webinars pertaining to the background principles of orthodontic mini implants/temporary anchorage devices (TADs), and their clinical applications with topics ranging from buccal insertion sites and the related biomechanics, and then progressing to more complex treatment plans involving molar intrusion and palate insertion sites. With this series, orthodontists can learn all of the background needed, with theory and clinical instructions, and then we plan to follow up with a hands-on component to complement the seminars. Besides the lecture material, a newly published textbook will provide real insight into TADs coupled with a series of detailed steps to follow for common clinical scenarios. This is an excellent adjunct to the series so that doctors can follow up by reading detailed instructions in the textbook. It helps you to feel more fully prepared.

I have been a Specialist Orthodontist since 1998 and developed an interest in bone anchorage since the year 2000, starting with palatal (osseointegrating) implants. I work as a consultant in the hospital system in the U.K. as well as having a private practice, and many of my patients are in need of orthognathic surgery and cleft palate treatment. When mini implants became available in the U.K. in 2003, I gradually built up my skill in this area. Over the last 10 years, as a result of a wide clinical case load, I have developed my extensive experience with mini implants

and use them in a range of applications.

Many of my cases are adults or older adolescents in need of mini implants, which are what we call TADs. A wide age range of people, e.g., 12-year-olds to 60-plus-yearolds, can benefit from these. Most patients tend to be 14 years old and up. To illustrate the importance of learning about this type of treatment, I can’t remember a single instance of an adult who has declined mini implants when his/her orthodontic options have been completely explained.

After using mini implants for 2 years, I realized that I was looking for particular design features and facets of the clinical kit. I approached an orthodontic supplier in the U.K. and asked if they could find a mini implant system somewhere in the world that could give me what I was looking for.

They responded that such a system did not yet exist, but then suggested that I design my own kit. By the end of 2005, I was working with this U.K. company, called DB Orthodontics Ltd, to develop the Infinitas Mini Implant System that has become the most widely used system in the U.K..

As interest grew in the U.S., Dentsply GAC selected my mini implant system for distribution about a year ago. This has resulted in my becoming a key opinion leader for GAC and has also led me into the lecture program for GCARE.

The first lecture of the five-part series is called, “Mini Implant Principles.” I strongly believe that orthodontists should both learn the theory of new procedures and also understand the practical steps. We discuss the principles, such as how mini implants work, the best time to use them, and what factors can affect their use. We then follow with typical clinical scenarios so that the clinicians can easily introduce mini implants in their own clinical practices, or if they already use them, to help them advance their techniques.

Mini implants are an adjunct to make orthodontic treatment more effective and efficient, so there are still lots of orthodontic problems treated without the need for TADs, but in key areas where anchorage needs to be reinforced, they offer robust, patient-friendly anchorage, which in the 21st century should replace the likes of headgear. In addition, different TAD-specific biomechanics offer better outcomes, such as control over incisor movement that results in better incisor torque. OP

Orthodontic practice 43

EDUCATION EXPLORATION

it comes to technology, but will never be more knowledgeable when it comes to knowing who you are, and how you want to be represented.

Besides website design and social media, recognition of the legalities of social media is also important. For example, a marketing release form is critical. Clinicians need a permission form for existing and new patients to place online information.

The challenge is that the legalities vary from state to state, so there is not just one release form that everyone in the U.S. can use. Every single patient needs to sign that form.

Yet another step is related to social media courtesy. If I am a patient, do I want to find out from another patient that my picture is on my orthodontist’s website, or is the “right thing to do” to pick up the phone and say, “Out of thousands of cases that I have done, I have decided to put up the best of the best. We would love your permission to add your case to our site?” That takes the patient from the annoyance of, “You put my case up? I didn’t know about it,” to the excitement of, “Dr. Shuman picked my case! Is it OK if I tell my friends?”

At the Pride Institute, we work hard to gain experience and provide the latest research to the orthodontic and dental community. One of my slides depicts 20 different social media icons. It is almost unfair for the orthodontist, whose role is to provide the best technical and personal care possible, to be asked to stay on top of all of these changes. The goal of this webinar series is to do just that; to provide a destination for the GAC Orthodontic community to be able to stay current and educated on how best to navigate through the social media community.

I work with orthodontic offices that continue to want to make online strategy a major goal, but every time I return to see what has progressed, it is still “a goal.”

Social media can no longer be a goal; it is a necessity. The facts back this up — 87 percent of the orthodontic target market is online daily. Consumer traffic looking for orthodontists and orthodontic knowledge is enormous. If a parent chooses an orthodontist, and the child checks online, and the orthodontist does not have a web or social presence, many will choose another orthodontist who does.

The goal of this webinar is to give a better understanding of Search Engine Optimization, to open the door to Google+

RESEARCH

Increasing practice efficiency and profitability using In-Ovation® R self-ligating brackets In their white paper, Dr. Jerry R. Clark and Jack Gebbie address questions about a specific self-ligating bracket system

M

any unsubstantiated claims have been made concerning self-ligating bracket systems as to their efficiency in moving teeth, the time savings that can be realized by using these appliances, and the “magic” that is somehow stored up in these brackets to more effectively align teeth. This study was done in an effort to draw some scientifically based conclusions to more accurately differentiate between what is “hype” and what is actually true regarding the purported increased efficiency and time savings of one such self-ligating bracket system – In-Ovation® R — manufactured by GAC International.

The study was performed to determine if cases treated with In-Ovation R brackets were actually treated faster, with fewer and shorter appointments, with less clinical chair time needed to complete treatment, and if they truly increase practice efficiency and profitability compared to similar cases treated with traditional edgewise brackets.

Are there other scientific studies available?

Recently, there has been a cry from the scientific community regarding evidence-

Jerry Clark, DDS, MS, is a board-certified orthodontist who maintains a full-time practice in Greensboro, North Carolina. He received his BS and DDS from the University of North Carolina and his MS in orthodontics from St. Louis University. He is also a Partner in Bentson Clark & Copple, a company that specializes in the sale and transition of orthodontic practices.

Mr. Jack Gebbie is president of Datatex, Inc. and has handled research projects for both national and regional companies for over 11 years with particular experience and expertise in the fields of healthcare and financial services. He is a graduate of Wake Forest University and is a member of CASRO (Council of American Survey Research Organizations), and conforms to the research integrity and standards established by this national organization. * Dr. Jerry Clark and Jack Gebbie would like to sincerely thank Debbie Terrell, Kyle Bechtel, and Dr. John Oubre for their efforts and invaluable assistance in accumulating data for this study. ** The complete study is available upon request by contacting GAC International.

44 Orthodontic practice

based studies that will differentiate between opinion and fact.1,2,3,4 It is important for our profession, if we are to remain rooted in scientific principles, to honestly research, study, and report on the claims made by our fellow professionals and the orthodontic supply companies. At the present time, there actually has been a surprising number of scientific studies performed that have reported the increased efficiency of self-ligating brackets.5-13 Most of these reports, however, have studied other bracket systems such as Damon® and Speed System™. To date no scientific study has been applied exclusively to the In-Ovation R bracket system to measure the treatment and chair time savings resulting from using this appliance. That is the reason for this research study.

How was this study performed?

Treated orthodontic cases were randomly selected from the practice of Dr. Jerry Clark, a board certified orthodontist. No attempt was made in this study to quantify the quality of the final treatment results.

It was assumed that Dr. Clark utilized all his technical skills and abilities to achieve the best treatment results possible for each individual patient. One hundred fourteen cases treated with In-Ovation R were studied and compared to 241 cases treated with traditional pre-torqued and pre-angulated brackets. This produced a confidence level for this sample of 95% +/-8%. Certain types of cases were eliminated from the study. Those excluded were: cases with an unusual number of missed or broken appointments; cases with an unusual number of loose or broken brackets; cases that required two-phase treatment; cases with significant skeletal discrepancies (Class III, skeletal open bites); cases with impacted canines; cases with extremely poor cooperation; and cases where some other circumstance significantly impacted Dr. Clark’s ability to complete treatment in a reasonable length of time.

This research project was managed by

Jack Gebbie, president, Datatex, Inc., an independent research and consulting firm specializing in market research. The data files were carefully reviewed, and marketing research standards were applied to the sampling to ensure comparisons would be valid across the two alternatives being studied. Datatex is a member of CASRO (Council of American Survey Research Organizations), and maintains research integrity and standards consistent with this organization.

What was specifically studied?

The study was fairly simple in its design.

Patients treated with traditional edgewise brackets, and Roth and Tweed type mechanics, with the goal of attaining the Andrews’ Six Keys to Occlusion,14 were compared to cases treated with In-Ovation R brackets and the light wire mechanics typically used with self-ligating brackets with the objective of achieving similar treatment objectives. The time required to place brackets at the beginning of treatment, and the time necessary to remove appliances at the end of treatment were not included, since it is realistic to assume that it takes approximately the same amount of time to place and remove brackets regardless of the type of brackets being used. What was studied was the actual treatment time from the day treatment was begun to the day appliances were removed. Also, the total number of patient visits needed to complete treatment was measured as was the total number of minutes of patient chair time necessary to complete treatment.

What were the findings of the study?

The average number of months required to treat cases utilizing In-Ovation R was 4.14 months less than comparable cases being treated using traditional edgewise brackets.

The average number of patient appointments needed to complete treatment was reduced by 6.66 appointments, which meant 40% fewer Volume 4 Number 2

RESEARCH Months in treatment

appointments were required to complete treatment using In-Ovation R compared to traditional edgewise appliances.

The number of minutes of clinical chair time that patients required in order to complete treatment was reduced by an average of 174.21 minutes per patient, or put another way, approximately 3 hours of chair time was saved on each treated patient.

That means the average case being treated with In-Ovation R took approximately 5 hours of chair time to treat, while the average case being treated with traditional appliances took almost 8 hours to treat, a time savings of approximately 36%.

How does the reduced chair time impact practice profitability?

Suppose your practice produces a profit of $350 per hour (an average figure for an active well-managed practice), and you are able to save 3 hours on each case you treat, then the profit for each case treated is increased by approximately $1,050.

However, In-Ovation R brackets do cost more than traditional edgewise brackets by approximately $5 per bracket. That means if you bond 5 to 5, you use approximately 20 brackets on each case for an additional expense of about $100 per case. So the actual estimated additional profit for each case using this scenario is about $950.

That is a pretty good return on an additional investment of $100 for In-Ovation R brackets. However, this is just an average.

If your practice profit per hour is less than $350 per hour, then your savings will be somewhat less. But, if your practice profit is more than $350 per hour, then your profit will increase even more.

Conclusions Granted, competent and conscientious orthodontists can most likely obtain 46 Orthodontic practice

Number of appointments

Chair time required to treat cases

excellent treatment results regardless of the type of appliances they choose to utilize.

I am often questioned by my colleagues, “Why should I change? Why should I pay more for In-Ovation R brackets when I am already achieving excellent results with my present bracket system?” The critical and more important question is, “What is best for our patients?”

If we as orthodontists are committed to providing the very finest treatment for our patients, I personally feel it is important that we look at the findings of this study, and

References 1. Turpin DL. Evidence-based orthodontics. Am J Orthod Dentofacial Orthop. 2000;118(6):591.

2. Huang GJ. Making the case for evidence-based orthodontics. Am J Orthod Dentofacial Orthop.

2004;125(4):405-406.

3. Turpin DL. Changing times challenge members…then and now. Am J Orthod Dentofacial Orthop. 2004;126(1):12.

4. Turpin DL. Putting the evidence first. Am J Orthod Dentofacial Orthop. 2005;128(4):415.

5. Harradine NWT. Self-ligating brackets and treatment efficiency. Clin Orthod Res. 2001;4(4):220-227.

6. Eberting JJ, Straja SR, Tuncay OC. Treatment time, outcome, and patient satisfaction comparisons of Damon and conventional brackets. Clin Orthod Res. 2001;4(4):228-234.

7. Shivapuja PK, Berger J. A comparative study of conventional ligation and self-ligation bracket systems.

Am J Orthod Dentofacial Orthop. 1994;106(5):472-480.

draw the obvious conclusions concerning the treatment of our patients. If we want to provide the very finest orthodontic care, in the most cost effective manner, with the least amount of discomfort to our patients, with the fewest number of visits required, provide shorter appointment times, and complete treatment as quickly as possible, I feel it now requires us to avail ourselves of the advanced technology of self-ligation.

Anything less would not be providing the finest available treatment for our patients. OP

8. Thomas S, Sherriff M, Birnie D. A comparative in vitro study of the frictional characteristics of two types of selfligating brackets and two types of pre-adjusted edgewise brackets tied with elastomeric ligatures. Eur J Orthod.

1998;20(5):589-596.

9. Pizzoni L, Ravnholt G, Melsen B. Frictional forces related to self-ligating brackets. Eur J Orthod.

1998;20(3):283-291.

10. Henao SP, Kusy RP. Evaluation of the frictional resistance of conventional and self-ligating bracket designs using standardized archwires and dental typodonts. Angle Orthod. 2004;74(2):202-211.

11. Damon DH. The rationale, evolution and clinical application of the self-ligating bracket. Clin Orthod Res. 1998;1(1):52-61.

12. Parkin N. Clinical pearl: clinical tips with System-R. J Orthod. 2005;32(4):244-246.

13. Harradine NW. Self-ligating brackets: where are we now? J Orthod. 2003; 30(3):262-273.

14. Andrews LF. The six keys to normal occlusion. Am J Orthod. 1972;62(3):296-309.

Volume 4 Number 2

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PRODUCT PROFILE

i-CAT® FLX — the latest advancement in Cone Beam 3D For greater flexibility in scanning, planning, and treatment i-CAT award-winning cone beam 3D dental imaging has already gained a wide reputation for image quality, patient safety, and smooth workflow. In the field of orthodontics, 3D scanning helps to increase surgical predictability and facilitate orthodontic treatment. i-CAT scans show true anatomy in full 3D volume and accurate and impressive 3D visualiza­ tion of teeth, roots and sinuses. With the precise data gathered from viewing an i-CAT scan and utilizing proprietary software tools, such as the Tx STUDIO™ software, orthodontists can obtain ceph tracings with greater accuracy and in less time than traditional 2D tracings. Practitioners can obtain a more thorough analysis of bone structure and tooth orientation, and as a result, treat patients with greater confidence.

Developed on the foundation of i-CAT excellence, the new i-CAT FLX cone beam 3D system offers a range of innovative features for greater clarity, easeof-use, and control. Practitioners can take advantage of these dynamic tools: • Visual iQuity™ advanced image technology delivers i-CAT’s clearest 3D and 2D images • Full dentition 3D imaging at a dose lower than a 2D Panoramic X-ray with QuickScan+* • Ergonomic Stability System (ESS) offers seated positioning, robust head stability, and adjustable seating controls to minimize patient movement and reduce the need for retakes. The unit is also wheelchair accessible • i-Collimator electronically adjusts the field-of-view to limit radiation only to the area of scanning interest • The i-CAT FLX offers a lower radiation dose than a panoramic X-ray • i-PAN™ technology produces traditional 2D panoramic images SmartScan STUDIO also works toward more clinical control by providing an easy, customizable solution for a more guided, controlled workflow in the dental practice. With its easy-to-use, touchscreen interface, and integrated acquisition system, SmartScan STUDIO offers stepby-step guidance, allowing the clinician to select the appropriate scan for each patient 48 Orthodontic practice

at the lowest acceptable radiation dose.

In addition to all of the clinical advantages, the small footprint of the i-CAT FLX also allows it to fit easily and seamlessly into any practice.

Of course, the i-CAT FLX also includes Tx STUDIO technology that is an integral part of all i-CAT cone beam 3D systems, which are known for their clinical and dose control, as well as the fastest workflow.

Tx STUDIO leverages the best in anatomy imaging software and cone beam 3D technology that benefits a gamut of specialties, from diagnostics to implant and orthodontic treatment planning. Using the new software in conjunction with the scans, the new face-MATCH™ photo wrapping feature offers easy and immediate wrapping of a facial photo taken with a standard digital camera onto the 3D volume to visualize treatment impact on soft tissue and facial features. Virtual study models in occlusion containing crowns, roots, and bone are also an option to predict soft tissue changes from orthodontic or surgical treatment. These software tools facilitate communication with other clinicians, and help dentists educate patients about their dental conditions, improving the possibility

of patient compliance to treatment. i-CAT continues to revolutionize 3D dental and maxillofacial radiography, with the launch of the new i-CAT FLX. OP About Imaging Sciences International Since 1992, Imaging Sciences International has been an innovator in advanced dental imaging, specifically with i-CAT cone beam technology. i-CAT solutions have been installed in more than 3,000 sites around the world. Imaging Sciences offers highly specialized service and support through the i-CAT Network and continuing education through the 3D Imaging Institute, the only its kind dedicated to helping entity of dentists and specialists use the latest in cone beam technology. * Data on file. Based on the number of scan options currently available at time of printing.

For more information on the i-CAT FLX or other i-CAT products, visit: http://www.i-cat.com/ This information was provided by Imaging Sciences International.

Volume 4 Number 2

!

EW N

©2013 Imaging Sciences International, LLC | ISI-Mktg-DM-0003Rev0

3D imaging for lower dose than a 2D panoramic* is not magic… …it’s The new i-CAT FLX is a reality!

This latest advancement of our award-winnning technology offers a range of innovative features that deliver increased clarity, ease-of-use, and control. Now with Visual iQuity™ and QuickScan+ technologies, the power of capturing diagnostic 3D images at a lower dose than a 2D panoramic x-ray is in your hands.

Schedule a demo today! Call 1-800-205-3570 or visit www.i-CAT.com Available exclusively through

*Utilizing the i-CAT FLX QuickScan+ exposure protocol. Data on file.

RESEARCH

Dental varnishes and their impact on enamel demineralization and bacterial inhibition: an in vitro model Drs. Mary Eve Maestre, Olivier F. Nicolay, Graham Walker, Michael Levi, and George J. Cisneros evaluate the effectiveness of certain fluoride varnishes Abstract Decalcification around orthodontic appliances remains a concern to the practicing clinician. Topical fluoride regimes have been shown to be effective but rely mostly on patient compliance.

Dental varnishes are an alternative to other topical preventive regimes that can be applied professionally every 3 to 6 months.

The purpose of this in vitro study was to evaluate the effectiveness of two fluoride varnishes, Duraflor™ and Fluor Protector C™, in preventing demineralization around orthodontic brackets. This study was undertaken in two parts. The first part of the study looked at the antibacterial properties of these varnishes in comparison to a control and a chlorhexidine varnish, Chlorzoin™. An in vitro system was set up where sterile beads were coated with each varnish and placed in a well containing an inoculum of a cariogenic strain of Streptococcus mutans in a sucrose broth.

The wells were incubated, and bacterial titers were determined at 24 and 48 hours.

In part 2 of this study, the effects of Duraflor and Fluor Protector C on enamel solubility were evaluated. Brackets were bonded to 60 extracted premolars with a traditional composite resin and randomly assigned into three different groups of 20

Mary Eve Maestre, DDS, is Clinical Assistant Professor, Dept. of Orthodontics, New York University New York, and she also has a practice in Manhattan.

Olivier F. Nicolay, DDS, MMSc, is Clinical Associate Professor, Dept. of Orthodontics, New York University.

Graham Walker, PhD., Professor, is from the Dept. of Mechanical Engineering, Manhattan College, Bronx, New York.

Michael Levi, ScD, is Associate Professor (Clinical), Dept. of Pathology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx.

George J. Cisneros DMD, MMSc, is a Professor, Dept. of Orthodontics, New York University.

50 Orthodontic practice

teeth. Group one served as the control, group 2 received a single application of Duraflor varnish, and group 3 Fluor Protector C varnish. All three groups were cycled in a pH cycling system, and were brushed with a fluoridated toothpaste two times per day to simulate mechanical wear for a total of 28 days. Demineralization around the orthodontic brackets was then evaluated by microhardness testing in three sites.

The result in part 1 showed that at 24 hours Chlorzoin >>> Duraflor > Fluor Protector C = control. At 48 hours Chlorzoin >>> Duraflor = Control < Fluor Protector C. The results in part 2 showed that Duraflor and Fluor Protector C equally inhibited demineralization by 25% relative to the control. The results of this study suggest that dental varnishes may be effective in preventing demineralization around orthodontic appliances.

Introduction/literature review Decalcification around orthodontic appliances remains a concern to the practicing clinician. In 1982, Gorelick, Geiger, and Gwinnett showed that white spot formation occurred on at least one tooth in 50% of cases debonded.1 A study carried out by Mitchell in 1992 showed a prevalence of white spot lesions occurring in 15% to 85% of cases debonded.2 The high incidence of decalcification following orthodontic treatment is quite disconcerting to the practicing orthodontist, as one of the primary goals in orthodontic treatment is to create esthetic and pleasing smiles.1,3,4,5 In the absence of excellent oral hygiene and preventive measures, the presence of orthodontic appliances encourages the accumulation of plaque, resulting in the formation of white spot lesions.6 Smales showed in 1981 that plaque tends to accumulate more on resinbonded materials than on enamel.7 A scanning microscope study carried out by

Gwinnett and Ceen in 1979 showed plaque distribution on bonded brackets. They found that one of the most common sites for demineralization was at the junction between the bonding resin and the enamel, usually just peripheral and gingival to the bracket base.8 Various preventive measures have been attempted to combat decalcification but have relied mostly on patient compliance, and are limiting in their effects, or have resulted in compromising the efficiency of orthodontic treatment.9-15

Topical fluorides are frequently used throughout the course of orthodontic treatment to prevent demineralization.3,9,10 Fluoridated dentifrices, mouth rinses and fluoride gels are routinely used for caries prevention.11 Studies have shown these methods to be effective in decreasing the rate of demineralization around orthodontic appliances.1,10 In a study carried out by Geiger, et al., in 1988, a 25% reduction in white spot lesions was observed in patients using a daily .05% sodium fluoride mouth rinse. However, they also found poor compliance occurred in 50% of patients, suggesting a need for a preventive method that will eliminate the patient compliance factor.16 The incorporation of fluoride into orthodontic materials has been a means by which the clinician can take preventive measures without relying heavily on patient compliance. Several fluoride-releasing adhesives have been shown to significantly reduce lesion development adjacent to orthodontic brackets.17 Fluoride-releasing composite resins have been shown not to have adequate fluoride release over time.15 Furthermore, bond strength values of fluoride-releasing composite resins have also been found to be lower than the bond strengths achieved with non-fluoridated composite resins.18

Dental varnishes have been developed as an alternative to other topical fluorides. It Volume 4 Number 2

was hoped that prolonged contact between teeth and the fluoride source would further reduce caries production.19 Clinical studies have shown that varnishes can supply fluoride more efficiently than other topical agents, and have reported reductions in caries after fluoride varnish application from 25% to 45% to as high as 75% when compared to controls, while others have reported little to no improvement.20-24

The purpose of this in vitro study was to evaluate the effectiveness of dental varnishes in inhibiting the caries process from both a microbiologic aspect and a physiochemical aspect. This was based on the premises that one can prevent enamel demineralization by targeting the microorganisms responsible for acid production or by rendering the dentition more resistant to the demineralizing process.

Materials and methods Part I: Antibacterial testing of three dental varnishes The antibacterial properties of the fluoride varnishes Duraflor and Fluor Protector C were determined and compared to a control, without any varnish, and to a known antibacterial varnish, Chlorzoin. A strain of S. mutans ATCC 33402 obtained from a carious tooth was maintained at minus 70 degrees. An overnight culture of S. mutans was inoculated into a sucrose broth so that the final concentration was about 5 x 105 CFLUs/ml. Sterile glass beads were coated with each varnish and allowed to harden for 4 to 6 hours. Uncoated sterile beads were used for controls. Each varnish was Volume 4 Number 2

assayed in 5 microtiter wells. One bead was dropped into each well followed by 100 μl of the inoculum. After 24 hours, the bacterial titers in each series of wells was determined by the spread plate dilution method. After an additional 24 hours, the bacterial titers assayed in 5 microtiter wells for each varnish were again determined by the spread plate dilution method.

Part II: Testing the effects of Duraflor and Fluor Protector C on enamel demineralization A) Dental varnish application followed by pH cycling Premolars extracted as part of an orthodontic treatment plan were collected at the Montefiore Medical Center. They were stored in a 1% thymol solution. A total of 60 premolars divided into three groups of 20 were used in the study. The teeth were pumiced and etched. Care was taken during the etching process that only the area of the bracket base was etched. This was accomplished by using a piece of tape with a cutout section equivalent to the area of the base of the bracket. Orthodontic brackets (3M Unitek™ victory series) were then placed and bonded with a light cure composite resin (3M Unitek Corporation).

All excess composite was removed from around the bracket prior to light curing.

The dental varnishes tested were Duraflor and Fluor Protector C . A total of 60 premolars divided into three groups of 20 were used in this study. Each group of 20 teeth was mounted upright in a soft acrylic mouth guard material (Figure 1). Mounting the teeth allowed all the teeth to be evenly

B) Microhardness testing The coronal portions of the teeth were sectioned buccolingually with a diamond disc through the center of the bracket. The sectioned halves were mounted in acrylic and polished with fine diamond discs in order to obtain a flat even surface (Figure 2). A flat, even surface was essential in performing the cross section hardness tests in order to accurately quantitate mineral loss and or mineral gain.

Microhardness tests were made across the cut face of the lesion and Orthodontic practice 51

RESEARCH

Figure 1: Premolars were suspended in a synthetic saliva solution. The solution was under constant circulation with a magnetic stirrer in an artificial saliva solution. The premolars were treated with a varnish and not brushed for 12 hours. Following the 12-hour period the teeth were brushed twice a day and the premolars were subject to an artificial caries solution for 1 hour twice a day. This was carried out over a 4-week period

exposed to the circulating medium and facilitated the brushing process.

The first group was the control group.

This group did not receive any type of varnish treatment. The second group received an application of Duraflor. The teeth were dried, and the varnish was applied evenly to the buccal surface of the premolars. The third group received an application of Fluor Protector C. The teeth were dried, and an even coat of Fluor Protector C was applied to the buccal surface of the premolars. The teeth were allowed to dry for 15 minutes to simulate manufacturer’s instructions that require Fluor Protector C to dry for 10 minutes.

Although Duraflor hardens in contact with saliva, the same protocol was followed to keep uniformity in the treatment of all the varnished groups.

Following this, the teeth were placed into three separate beakers containing a synthetic saliva solution consisting of 20 mM NaHCO3, 3 mM NaH2PO4, and 1 mM CaCl2 at a pH of 7.5 at room temperature as per Todd and co-workers, 1999.24 The solution was under constant circulation via a magnetic stirrer (Figure 1). The teeth were not brushed for 12 hours to simulate instructions given to the patient that require no brushing for the rest of the day. This is recommended by the manufacturer to allow for prolonged exposure of the enamel to the fluoride. Following this time period, the teeth were brushed two times a day with fluoridated toothpaste. All teeth were subjected to an artificial caries solution, consisting of 2.2 mM Ca+2, 2.2 mM PO4, and 50 mM acetic acid at pH 4.4 as per Todd and co-workers, 1999.24 This was carried out for 1 hour twice a day.

The teeth were kept in the in vitro baths under constant circulation for up to 4 weeks (Figure 1). At the completion of the cycling process, the teeth were removed from the beakers and prepared for the microhardness testing.

RESEARCH

Figure 2: The premolars were cross-sectioned and embedded in acrylic. Measurements were taken at 500µm from the periphery of the bracket towards the occlusal, the cervical and underneath the bracket. Microhardness tests were performed at 25µm, 50µm and at 25µm intervals up to 300µm using the Knoop hardness tester

Figure 3 Antibacterial Properties of Duraflor™, Fluor Protector™ and Chlorzoin™

into the inner enamel at three points with respect to the orthodontic bracket: 500 μm cervical and occlusal to the bracket and directly underneath the bracket (Figure 2). The testing underneath the bracket was performed to ensure that the demineralization observed was a result of the pH cycling and not initial acid etching procedures. At each point, hardness tests were made at 25 μm, 50 μm, and at 25 μm intervals up to 300 μm with respect to the surface enamel using the Knoop hardness tester. Indentations were made with the long axis of the diamond indentor parallel to the outer enamel surface (Figure 2). The length of the diamond indentation was determined in filar units and converted to the Knoop hardness number by using the following formula:

KHN = L/(I.C). Volume percent mineral was then calculated by using the formula V%(mineral)=4.3(14230K)1/2/I + 11.3.25

Statistical Analysis In part 1, an analysis of variance and a Duncan’s multiple range test were used to compare the antibacterial effects of three dental varnishes, Chlorzoin, Duraflor, and Fluor Protector, relative to an unvarnished control.

In part 2, small sets of untreated teeth were used initially to assess the variability in measures of demineralization and hardness. The estimate of variability was used as part of a power analysis to determine sample size. Differences among the groups with regard to demineralization and hardness were tested using an analysis of variance since assumptions of normality and equal variance were met. A Duncan’s multiple range test was used in conjunction with the analysis of variance to control 52 Orthodontic practice

Table I - 24 Hours ∆ LOG

TREATMENT

LOG COLONIES/PLATE

Control

6.05

Duraflor™

4.89

-1.16

Fluor Protector C™

6.08

+0.03

Chlorzoin™

No growth Table II - 48 Hours ∆ LOG

TREATMENT

LOG COLONIES/PLATE

Control

4.95

Duraflor™

5.26

+0.31

Fluor Protector C™

6.33

+1.38

Chlorzoin™

No growth

for multiple comparisons among groups.

All tests were performed using an overall alpha level of .05.

Results Part I - Antibacterial testing Table I illustrates the antibacterial effects of Duraflor, Fluor Protector C, and Chlorzoin at 24 hours. Chlorzoin exhibited a complete inhibitory effect at 24 hours.

A comparison of the fluoride varnishes to the chlorhexidine varnish showed that Chlorzoin had a complete inhibitory effect followed by Duraflor with a slight inhibitory effect, and Fluor Protector C showed no significant inhibitory effect at 24 hours, such that Chlorzoin >>>Duraflor >control = Fluor Protector C. Table II illustrates the antibacterial effects of Duraflor, Fluor Protector C, and

Chlorzoin at 48 hours. At 48 hours, the Duncan’s Multiple Range test showed that a comparison of Duraflor and the control exhibited no significant difference.

At 48 hours, Duraflor lost its antibacterial properties. Fluor Protector C demonstrated a slight significant difference from the control and Duraflor where, in fact, we found that growth appeared to be slightly promoted at 48 hours. Chlorzoin showed a significant difference from the two fluoride varnishes and the control. At 48 hours, Chlorzoin maintained its antibacterial effectiveness, such that Chlorzoin >>> Duraflor = control < Fluor Protector C. Part II – Microhardness testing 500μm occlusal to the periphery of the bracket In Figure 3, the results at 500μm occlusal Volume 4 Number 2

RESEARCH

Figure 4

from the periphery of the bracket base are compared. At the depth of 25μm, the control group demonstrated a mineral loss of approximately 25% tapering off to 15% at 75μm, 10% at 100μm to essentially normal enamel at 125μm. The Duncan grouping analysis illustrated this effect as being significantly different (p<.05). Duraflor and Fluor Protector C behaved statistically the same. They exhibited an initial mineral loss of 5% at 25μm and 50μm to relatively normal enamel at 100μm. A comparison of the control to Duraflor and Fluor Protector C, using the Duncan grouping analysis, demonstrated significance for the first three points (25μm up to 75μm) with no difference thereafter.

Underneath the bracket In Figure 4, the hardness profiles for the control, Duraflor and Fluor Protector C underneath the bracket are illustrated.

The control, Duraflor and Fluor Protector C exhibited similar percent mineral profiles with essentially the same mineral content from 25μm to 300μm. The Duncan grouping analysis showed no significant difference among the three groups at each distance. In addition, the Duncan grouping analysis showed no significant differences among the distances within each group (P>.05).

500μm cervical to the periphery of the bracket In Figure 5, the microhardness profiles are compared at 500μm cervical to the periphery of the bracket base. The control teeth exhibited significant mineral loss from 25μm to 300μm. At 25μm, the control teeth exhibited an initial 12% mineral loss to 4% mineral loss at 175μm. Duraflor and Fluor Protector C both exhibited an initial mineral loss of 4% at 25μm to essentially normal Volume 4 Number 2

Figure 5

enamel at 100μm. The Duncan grouping analysis comparing the control, Duraflor and Fluor Protector C, showed a significant difference between the control and the two varnishes (Duraflor and Fluor Protector C) that consistently behaved similarly from 25μm to 175μm. In addition, a significant difference can be observed at 275μm and 300μm in the control group. At this point, the effects of the demineralization and the encroachment on the dentino-enamel junction may have led to the decrease in mineral content.

Discussion This study showed that a single application of Duraflor or Fluor Protector C on the labial surface of a tooth, with a previously bonded orthodontic bracket, can significantly reduce demineralization by as much as 25% when compared to a control. A study of the antibacterial properties of Duraflor and Fluor Protector C showed their relative ineffectiveness at 24 and 48 hours when compared to Chlorzoin, a chlorhexidine containing varnish, and a control. This in vitro study suggests how dental varnishes could be used to prevent demineralization adjacent to orthodontic brackets during treatment.

The practicing clinician is often confronted with the noncompliant patient where other preventive regimes have proven to be unsuccessful. Usually these patients are in the middle of orthodontic treatment, and steps need to be taken to prevent demineralization from occurring so that therapy can be successfully completed. Fluoride varnishes offer the clinician an opportunity to take immediate preventive action. These varnishes must be applied professionally every 3 to 6 months, thereby reducing the need for patient

compliance.

The in vitro part of the study was designed in two parts in order to look at the antimicrobial activity of these varnishes separately from the physiochemical properties. In the first part of this study, an in vitro system was set up to assess the antibacterial properties of three dental varnishes. The results from this part suggest that fluoride has a limited antibacterial effect. Duraflor shows some inhibitive advantage over that of Fluor Protector C, and most likely can be attributed to the higher concentrations of fluoride present in Duraflor. However, even in Duraflor, the antibacterial effects are very limited in duration and probably should be of very little use in the in vivo environment. These findings were not entirely unexpected as Loveren, et al., in 1984, have shown that the metabolic inhibition of cell suspensions in contact with fluoridated enamel is not permanent and disappears quickly.26 The therapeutic action of fluoride has been shown to involve a number of effects on enamel and dental plaque. However, the concentration of fluoride required to reach a desired effect may differ by five orders of magnitude.27 Fluoride concentrations required to inhibit dental plaque formation and bacterial metabolism are significantly higher than the concentrations required in reducing enamel solubility and enhancing remineralization.27 The initial concentration of fluoride in Duraflor may have been high enough to result in some bacterial inhibition initially, but decreased concentrations over time resulted in the loss of antimicrobial activity. The fluoride levels in Fluor Protector C were never high enough to result in any antimicrobial activity. In fact, at 48 hours, Duraflor lost its antibacterial properties, and Fluor Protector C Orthodontic practice 53

RESEARCH demonstrated a significant difference from the control and Duraflor where we found that growth appeared to be promoted.

We hypothesize that this may have been an artifact created by our in vitro system.

At 48 hours, the control appears to have reached a stationary phase where growth has diminished as the nutrient source was depleted. Fluor Protector C allowed for continued bacterial growth. Although the exact composition of the varnish is unknown, perhaps carbon and nitrogen polymers present in the varnish served as a nutrient source allowing for sustained bacterial growth.28 The “gold standard” varnish that we used, Chlorzoin, appears to be the varnish of choice when preventing dental decay from an antibacterial perspective.

Chlorhexidine has been shown to be a highly effective antimicrobial agent.

Although resistance to chlorhexidine has been documented against bacterial species such as Staphylococcus aureus and Streptococcus sanguis, a study carried out by Jarvinen, Tenovuo, and Huovinen in 1993 showed that chlorhexidine was highly effective against all Streptococcus mutans isolates.29 A study by Sandham, Nadeau, and Phillips in 1992 showed that a single application of chlorhexidine varnish suppressed oral mutans streptococcal levels for at least 3 months and up to 7 months in orthodontic patients.30 In 1999, Achong and co-workers carried out a study to determine the effect of chlorhexidine varnish mouth guards on the levels of S. mutans in caries active pediatric patients.30 One week of nightly use of the chlorhexidine varnish mouth guard resulted in a significant decrease in S. mutans levels that lasted for up to 3 months. This varnish offers the clinician another way to prevent decay.

Although chlorhexidine rinses have several disadvantages, such as staining of teeth, disturbances of taste, increased calculus formation, and minor oral irritations, none of these side effects have been observed with the use of chlorhexidine in the varnish form.31 Chlorhexidine varnish is currently being used to treat patients in Europe and in Canada. In the United States, approval is currently being requested from the Food and Drug Administration for two chlorhexidine varnish systems, Chlorzoin™ (Knowel Therapeutic Canada) and Cervitec™ (Viadent, Orion Diagnostica, Finland).

Although fluoride has antimicrobial effects, these effects in caries prevention 54 Orthodontic practice

may be of little significance as compared with the direct interactions of fluoride with enamel during lesion development and progression. In part 2 of this study, a demineralization/demineralization in vitro system was used to further investigate the caries preventive effects of fluoride present in Duraflor and Fluor Protector C in a system that eliminates the microbiologic component of the caries process and focuses on the physiochemical effects of fluoride on enamel solubility was used.

This study illustrated that a significant amount of demineralization, as determined by microhardness testing, was evident after 1 month of pH cycling. A mineral loss of up to 25% was seen occlusal and cervical to the bracket in the control group at depths of 25 to 100μm from the buccal surface. A previous in vivo study by O’Reilly and Featherstone showed mineral losses of up to 15% both occlusal and cervical to the orthodontic brackets after 1 month, suggesting that the demineralizing process around orthodontic appliances occurs soon after appliance placement.10 The fluoride varnishes were equally effective in preventing demineralization.

In both varnishes, only a 5% mineral loss was observed occlusal and cervical to the periphery of the bracket base at depths ranging from 25 to 100μm. The control group in the cervical region appeared consistently more demineralized than the two varnish groups. It appears that the enamel in this region is more susceptible to demineralization. This may be because the enamel is thinner in the cervical area.

However, the effects of the two fluoride varnishes rendered the enamel in this region with similar volume percent mineral content as normal enamel at 100μm.

Moreover, one could hypothesize that the protective effect of these varnishes was not due to the anticariogenic effects of fluoride but rather by the barrier effect created by the varnish coating. To simulate the clinical situation as much as possible, the teeth were brushed two times a day with fluoridated toothpaste. Visual inspection of the teeth treated with Duraflor, which forms a yellow coating on the buccal surface, showed complete removal of the varnish after 1 week. Therefore, it is evident that the protective effect was due in large part to the action of fluoride and not completely as a result of a barrier effect created by the varnish coating.

Several mechanisms for the action of fluoride have been proposed. For many

years, it was believed that the primary preventive effect of fluoride was a result of the incorporation of fluoride into the apatite lattice leading to a reduction in enamel solubility. However, studies have shown that bound fluoride plays a limited role in the cariostatic effects of fluoride. This was observed in a study where teeth consisting of fluoroapatite (shark enamel) developed a caries defect.32 Another study using rats with structurally incorporated fluoride failed to show a significant reduction in caries rate.33 Nevertheless, in both studies, it was found that the introduction of low levels of free fluoride significantly reduced the caries rate.

The anti-caries action of free fluoride in the aqueous phase has been shown to be due to the inhibition of demineralization at the crystal surfaces within the tooth and the enhancement of remineralization resulting in the arrestment or reversal of carious lesions.34 The reaction of fluoride with calcium, acid phosphates, and carbonates forms a number of fluoridated phases, “CaF2-like” compounds, that adsorb onto the enamel surface and are believed to play a major role in the cariostatic mechanism of topically applied fluorides.32 A study

by Margolis and Moreno showed that the maximum anti-caries effect of fluoride is achieved by maintaining low levels of free fluoride in plaque fluid.34 Duraflor and Fluor Protector C are equally effective varnishes. A consideration of their advantages and disadvantages allows the clinician to choose the ideal varnish to fulfill the needs of his/her particular patient population and their office needs.

The concentration of fluoride in Duraflor is significantly higher at 5% than the concentration of fluoride in Fluor Protector C at only 0.1%. This may be of importance to the clinician who is concerned about the possibility of overexposing his/her patients to excessive amounts of fluoride.

However, these varnishes have been shown to induce low plasma levels of fluoride, thereby proving to be reasonably safe to use in children.21 The effectiveness of Fluor Protector C, despite its lower fluoride concentration, is attributed to its acidic properties. A study by Ogaard in 1988 showed that a topical application of fluoride at a low pH was more effective than neutral NaF topical applications.35

Fluor Protector C is more esthetic than Duraflor. Duraflor hardens into a yellowish brown coating whereas Fluor Protector Volume 4 Number 2

References 1. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod. 1982;81(2):93-98.

2. Mitchell L. An investigation into the effect of a fluoride releasing adhesive on the prevalence of enamel surface changes associated with directly bonded orthodontic attachments. Br J Orthod. 1992;19(3):207-214.

3. Ogaard B, Rølla G, Arends J, ten Cate JM. Orthodontic appliances and enamel demineralization.

Part 2. Prevention and treatment of lesions. Am J Orthod Dentofacial Orthop. 1988;94(2):123-128.

4. Mizrahi E. Enamel demineralization following orthodontic treatment. Am J Orthod. 1982;82(1):62-67.

5. Zachrisson BU, Zachrisson S. Caries incidence and oral hygiene during orthodontic treatment. Scand J Dent Res. 1971;79(6):394-401.

6. Glatz EGM, Featherstone JDB. Demineralization related to orthodontic bands and brackets – a clinical study. Am J Orthod. 1985;87:87.

7. Smales RJ. Plaque growth on dental restorative materials. J Dent. 1981;9(2):133-140.

8. Gwinnett AJ, Ceen RF. Plaque distribution on bonded brackets: a scanning microscope study. Am J Orthod.

1979;75(6):667-677.

9. Geiger AM, Gorelick L, Gwinnett AJ, Benson BJ. Reducing white spot lesions in orthodontic populations with fluoride rinsing. Am J Orthod Dentofacial Orthop.

1992;101(5):403-407.

10. O’Reilly MM, Featherstone JD. Demineralization and remineralization around orthodontic appliances: an in vivo study. Am J Orthod Dentofacial Orthop.

1987;92(1):33-40.

11. Chadwick BL. Products for prevention during orthodontics. Br J Orthod. 1994;21:395-398.

12. Joseph VP, Grobler SR, Rossouw PE. Fluoride release from orthodontic elastic chain. J Clin Orthod.

1993;27(2):101-105.

13. Underwood ML, Rawls HR, Zimmerman BF.

Volume 4 Number 2

Further studies are required to determine the effectiveness of these varnishes. Since in vitro studies do not take into account the complex biological processes that occur in vivo, long-term clinical trials with large sample sizes will be important to accurately assess the preventive effects of these varnishes. In addition, studies need to be undertaken to determine the frequency of application of these varnishes on orthodontic patients that would allow for the maximum benefit.

Whether to use a chlorhexidine varnish versus a fluoride varnish needs to be further investigated. Clinical trials comparing the effectiveness of these varnishes would further elucidate the advantages and disadvantages of each varnish. It would be interesting to combine the anti-cariogenic agents from each of the varnishes namely, chlorhexidine and fluoride, into a single varnish in order to determine if they would have a synergistic effect in combating the caries process.

Clinical evaluation of a fluoride-exchanging resin as an orthodontic adhesive. Am J Orthod Dentofacial Orthop.

1989;96(2):93-99.

14. Lippitz A, Staley RN, Jakobsen JR. In vitro study of 24-hour and 30-day shear bond strengths of three resin-glass ionomer cements used to bond orthodontic brackets. Am J Orthod Dentofacial Orthop.

1998;113(6):620-624.

15. Bishara SE, Swift EJ Jr., Chan DC. Evaluation of fluoride release from orthodontic bonding system. Am J Orthod Dentofacial Orthop. 1991;100(2):106-109.

16. Geiger AM, Gorelick L, Gwinnett AJ, Griswold PG. The effect of a fluoride program on white spot formation during orthodontic treatment. Am J Orthod Dentofacial Orthop. 1988;93(1):29-37.

17. Ogaard B, Rezk-Lega F, Ruben J, Arends J. Cariostatic effect and fluoride release from a visible lightcuring adhesive for bonding of orthodontic brackets. Am J Orthod Dentofacial Orthop. 1992;101(4):303-307.

18. Fox NA, McCabe JF, Gordon PH. Bond strengths of orthodontic bonding materials: an in-vitro study. Br J Orthod. 1991;18(2):125-30.

19. Yanover L. Fluoride varnishes as cariostatic agents: a review. J Can Dent Assoc. 1982;48(6):401-404.

20. Clark DC, Stamm JW, Robert G, Tessier C. Results of a 32-month fluoride varnish study in Sherbrooke and LacMegantic, Canada. J Am Dent Assoc. 1985;111(6):949953.

21. de Bruyn H, Arends J. Fluoride varnishes: a review. J Biol Buccale. 1987;15:71-82.

22. Koch G, Petersson LG. Caries preventive effect of a fluoride-containing varnish (Duraphat) after 1 year’s study.

Community Dent Oral Epidemiol. 1975;3(6):262-266.

23. Tewari A, Chawla HS, Utreja A. Comparative evaluation of the role of NaF, APF & Duraphat topical fluoride applications in the prevention of dental caries — a 2 1/2 years study. J Indian Soc Pedod Prev Dent.

1991;8(1):28-35.

Conclusion Enamel demineralization following orthodontic treatment is a problem frequently encountered by the practicing orthodontist. Fluoride varnishes should be incorporated into the clinician’s armamentarium to help minimize the development of this condition.

1. Duraflor was found to have a limited antibacterial effect, and Fluor Protector C had no antibacterial effects.

2. Chlorzoin was found to be far superior in its antimicrobial effectiveness than either of the two fluoride varnishes.

3. Duraflor and Fluor Protector C were both equally effective in preventing demineralization. A 25% decrease in the demineralization was observed when compared to the control.

4. The results of this study demonstrate that fluoride varnishes may be effective in preventing demineralization around orthodontic appliances. OP

1999;116(2):159-167.

25. Arends J, Schuthof J, Jongebloed WG. Lesion depth and microhardness indentations on artificial white spot lesions. Caries Res. 1980;14(4):190-195.

26. Van Loveren C. The antimicrobial action of fluoride and its role in caries inhibition. J Dent Res. 1990;69(special issue):676-681.

27. Tatevossian A. Fluoride in dental plaque and its effects. J Dent Res. 1990;69(special issue):645-652.

28. Byers HL, Homer KA, Beighton D. Utilization of sialic acid by viridans streptococci. J Dent Res. 1996;75(8):1564-1571.

29. Järvinen H, Tenovuo J, Huovinen P. In vitro susceptibility of Streptococcus mutans to chlorhexidine and six other antimicrobial agents. Antimicrob Agents Chemother. 1993;37(5):1158-1159.

30. Sandham HJ, Nadeau L, Phillips HI. The effect of chlorhexidine varnish treatment on salivary mutans streptococcal levels in child orthodontic patients. J Dent Res 1992;71(1):32-35.

31. Achong RA, Briskie DM, Hildebrandt GH, Feigal RJ, Loesche WJ J. Effect of chlorhexidine varnish mouthguards on the levels of selected oral microorganisms in pediatric patients. Pediatr Dent.

1999;21(3):169-175.

32. Ogaard B, Rölla G, Ruben J, Dijkman T, Arends J. Microradiographic study of demineralization of shark enamel in a human caries model. Scand J Dent Res. 1988;96(3):209-211.

33. Larson RH. Animal studies relating to caries inhibition by fluoride. Caries Res. 1977;11(suppl 1):42-58.

34. Margolis HC, Moreno EC. Physiochemical perspectives on the cariostatic mechanisms of systemic and topical fluorides. J Dent Res. 1990;69(special issue):606-613.

35. Ogaard B. Applicability of acid-etching techniques for fluoride determination on enamel after topical fluoride treatment. Acta Odontol Scand. 1988;46(6):337-340.

24. Todd M, Staley R, Kanellis MJ, Donly K, Wefel JS. Effect of a fluoride varnish on demineralization adjacent to orthodontic brackets. Am J Orthod Dentofacial Orthop.

Orthodontic practice 55

RESEARCH

CTM hardens into a transparent film. Both varnishes have been found to have an unfavorable taste to patients.

The application of Fluor Protector C is more technique sensitive than Duraflor.

Fluor Protector C needs to be applied and allowed to harden in a dry environment.

This would require patient cooperation and increased chair time. The application of Duraflor is less technique sensitive since it hardens when it comes in contact with saliva. This would allow for ease of application in uncooperative patients and reduced chair time.

Perhaps one could use both varnishes in a single patient. Duraflor can be applied in the posterior quadrants where moisture control and visibility are more difficult, and Fluor Protector C can be applied in the anterior segments where esthetics is more of a concern. Therefore, one can tailor the fluoride varnish applications to fulfill a patient’s needs in addition to facilitating the application process.

PRACTICE MANAGEMENT

Avoiding employment claims and lawsuits Eilene Verret and Gibson Pratt discuss how to prevent major employee issues

W

hile it may not rise to the same level of alarm as your front desk telling you a 60 Minutes film crew and interviewer are in your waiting room asking to speak to you, a claim or lawsuit filed against you by a former employee can be just as problematic. And, it promises to have a very long and disruptive shelf life. It will unquestionably be an emotional and disruptive force in your practice, and it will result in lots of money trading hands between you and lawyers.

“Are you telling me I can’t terminate an employee any time I want to,” you ask? Yes, you can. It is true that while most employees do not have written employment contracts and are considered “at-will” employees in most states, that does not insulate you from claims and lawsuits.

There are two primary attacks for the disgruntled former employee to launch in an effort to obtain money from you. The first is by way of a claim of discrimination filed with the local labor department or the U.S. Equal Employment Opportunity Commission (EEOC). Those claims are typically not screened well at the EEOC and are generally based on allegations of unfair treatment due to race, color, religion, sex (including pregnancy), national origin, age (over 40), disability, or genetic information. They can result in the EEOC proceeding against you or issuing a right to serve letter to your former employee. The second is a lawsuit filed directly against you for the creation/maintenance of a hostile or abusive work environment which is based on harassment rather than discrimination.

Gibson Pratt is Vice President and General Counsel of OrthoSynetics. He left his law firm in San Diego, California where he was partner specializing in corporate transactions and litigation to join OrthoSynetics in 2001. He received his BA degree from the University of Arizona and JD from California Western School of Law. Eilene Verret, PHR, Director of Human Resources, has been employed by OrthoSynetics for 15 years. She received her Bachelor of Science Degree in Business Management with HR Concentration from Louisiana State University, and she is also a Certified Professional of Human Resources.

56 Orthodontic practice

So, how do you minimize, if not altogether eliminate such potential disasters?

Maintain policies

written

employment

Regardless whether you create an employee handbook or simply post them online for employees to view, this is the single most important step to protect you as an employer. Outline the necessary procedures for employees to follow in the event they believe they have been subjected to discriminatory behavior under Title VII of the Civil Rights Act, i.e., age discrimination, sex discrimination, or racial discrimination, the Americans with Disability Act, or the Family Medical Leave Act. Employers should make payroll policies available to employees to avoid costly wage claims, and everyday operational policies to reduce unemployment claims.

Create job descriptions Doing so allows an employer to clearly outline the responsibility, requirements, and expectations for each position. Present the written description to an employee upon hire, so they may review and sign it.

This document should become part of the personnel file.

Develop a comprehensive performance management program Regardless of an employee’s performance, schedule and conduct performance reviews after the first 90 days of employment and upon annual anniversary dates. Set measurable and realistic performance goals, and determine how the supervisor will help the employee succeed and reach those established goals. Communicate in a timely manner if an employee is not meeting those goals. Don’t ever assume an employee knows that he/she is not performing up to your expectations. Make sure to discuss with them when necessary.

Provide employee training

one to suffer the consequences. Whether it is simple internal training among peers or a 2-day seminar offered by an association or company, training is worth its weight in gold.

Maintain fair and consistent treatment of all employees Labor laws are put in place to protect employees. However, there are several areas that are not regulated, but could still cause an employer legal headaches.

They include time off (paid and unpaid), work schedules, and compensation. An employer should never show favoritism. If you have written policies as outlined above, then follow them.

Perform employment verification and reference checks They are not easy to get because all employers are wary of a lawsuit. However, there is always one failproof question you can ask, and nine times out of 10, the answer speaks for itself. “If given the opportunity, would you hire this individual again?”

Severance agreements You can consider entering into a written severance agreement with the employee you intend to terminate by offering to pay some money he/she would not otherwise be entitled to, measured by weeks or days of salary in exchange for a full and complete release of all claims he/she could raise against you, whether known or unknown. It is worth the money in most cases to eliminate the risk.

Employment Practice Insurance (EPLI)

Liability

Lastly, employers can secure EPLI, but with deductibles that can be high, it simply guards an employer against catastrophic lawsuit loss. Everyone has the right to file a lawsuit. You have the knowledge to protect yourself against one. OP

An employer is ill advised to throw an employee into a new position or task to sink or swim. The employee is set up to fail from the start, and your practice will be the

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PRACTICE MANAGEMENT

Observations on growing an orthodontic practice: part 2

Chris Bentson continues his discussion on how to grow a practice with a sound foundation

A

s mentioned in part one of this article, featured in the January/February 2013 issue of Orthodontic Practice US, an orthodontic practice must have good systems in place. Without a sound system foundation, practice growth cannot occur.

Perhaps the most important sequence of events to grow a practice is the patient enrollment process. Let’s begin part 2 of our observations on growing a practice with a discussion of the new patient process, and the importance to improve and polish the systems that surround it.

Start more patients There is a series of milestones nearly every new patient must pass in order to get to a start. Perhaps the most traditional view is: 1. New patient phone call 2. New patient exam

Chris Bentson, president, Bentson Clark & Copple, LLC of Greensboro, North Carolina, has been working with orthodontists regarding the business aspects of their practices for more than 23 years. He also serves as editor-in-chief of the Bentson Clark reSource, a quarterly newsletter focused on the business aspects of running a successful orthodontic practice. He is a frequent guest lecturer and has personally visited over 1,000 orthodontic practices in the United States, Canada, and Australia. He can be reached at 1-800621-4664 or via email at Chris@bentsonclark.com.

58 Orthodontic practice

3. Records 4. Consultation 5. Separator or bonding/banding Collectively, these steps could be described as the production wheel for a practice, and executing at the highest level in each of these areas is a skill set.

There are multiple systems in the production wheel. Consider what it takes to get a potential patient to pick up the phone and schedule a new patient exam. That process can touch many areas, including marketing, website, SEO, online reviews, referring relationships, patient referrals, etc.

When the office phone rings, who picks it up? What does he/she say? How does he/ she say it? Does that change at 3 in the afternoon? Is something mailed or emailed afterward; if so to whom? Whew, lots of areas that need to be done extremely well, and we’re not even to step two — the new patient exam, which is far more complex.

Truth be told, most orthodontists do a great job once they get to do doctor stuff. Many practices do not do a good job in all steps of the production wheel described above. Doing everything well takes training, scripting, and timing.

Growing practices focus a great deal of resources in perfecting these systems that lead to production. Consultants are a great benefit to the practice owner who needs

improvement in any of these steps.

Interestingly, the Journal of Clinical Orthodontics’ (JCO) Orthodontic Practice Study reports that, on average, over the last 30 years of the studies, less than 17% of practices engaged with a practice consultant. Yet, consistently over this time period, the data reported in the studies show that those who do use a practice consultant start significantly more cases (223.8 case starts for practices that do not use a consultant versus 285.7 starts for those that do in the most recent 2011 JCO’s Orthodontic Practice Study).

In our valuation studies, we consistently observe that practices that invest with management consultants are larger, typically value higher, and measure above norms in almost every financial and operational metric. Practices owners who want to grow are well served by getting sound systems in place with an emphasis on executing all the necessary systems needed to get a patient to start.

Even very mature practices see continual improvement in this area with the use of consultants as the backbone of polishing the new patient process.

Find more patients To grow a practice in today’s economic environment with today’s consumer Volume 4 Number 2

Volume 4 Number 2

Remember that growth is a choice; it’s intentional. Growth takes an investment of time, money, and monitoring.

Consultants can help in the growth process.

Product mix Besides aligner therapy, there are a number of newer treatment modalities available to orthodontists practicing today versus 10 years ago. Some companies producing these products have been very successful in marketing their product directly to the consumer. Consider Invisalign® and Damon® in particular. Has a patient called the practice to ask about Invisalign? Or Damon? Or clear braces? The answer is probably yes.

Examine Invisalign sales (since they are public, they are reported), and one will find that since the recession ended in the second quarter of 2009, their shipments to orthodontists have gone from 17,970 cases per quarter to 35,885 as of the third quarter in 2012. The aligner business to orthodontists has doubled in the last 40 months. The number of orthodontic practices submitting Invisalign cases has gone from about 3,600 in 2009 to 4,660 as of the third quarter of 2012. This means that the 4,660 orthodontists currently are submitting an average of 7.7 cases a quarter or 30.8 cases a year.

Understandably, there are other aligner products available from other companies, but the point is that just about 50% of the practices in the country utilize Invisalign. Those practices have almost doubled their use of the product over the last 40 months, a difficult time for growth for many practices. The question is, does

adding aligner treatment to a practice’s product mix make sense? Opinions differ, but if there is a desire to grow, the evidence seems to indicate that growth can be added to a practice with aligner technology as a component.

We often hear orthodontists tell us that one of the reasons they do not offer aligner treatment is that “every general dentist is offering it in their area.” Again, the facts from Invisalign do not bear this.

The most recent Invisalign sales data from the third quarter of 2012 reports that 11,925 general dentists submitted 34,725 cases in the quarter, for an average of 2.9 cases per quarter. There are about 130,000 practicing general practitioners in the country, meaning that only 9.1% of the practicing general dentists are submitting cases. Put another way, 90.9% of the general dentists are not submitting cases.

The argument that large percentages of general dentists are taking the orthodontic market share is just not so.

Some growing practices are adding lab-intensive products or consumer branded products to their product mix in order to differentiate or offer multiple types of treatment. Some examples are: SureSmile® (OraMetrix), Itero™ (Cadent), Incognito™ (3M), i-braces™, Damon, Insignia™, as well as all types of clear and esthetic brackets. There is much discussion about a raft of forthcoming scanning products. Most of these options are either higher priced products to the orthodontist or have lab fees associated with them.

Practices that invoke these systems or technologies are often successful branding or differentiating their practice with these offerings. However, practice owners must carefully analyze and balance the cost/ benefit ratio, as overheads often increase with many of these treatment options.

Buying a competitor The mean age of the practicing orthodontist in North America has been rising year after year and is now approximately 54 years of age. We will be seeing more practices come on the market as a result, and many of these practices will be good opportunities for younger practitioners to purchase and merge into their existing practice. This merger and acquisition idea was rampant in the mid- and late 1990s in corporate America. It is an idea Orthodontic practice 59

PRACTICE MANAGEMENT

behavior, one may need to develop the skill of locating patients. Practices that learn how to find patients are growing at high rates. The first question to ask is, where are they? In large numbers, they are located in four places: 1. In one’s reception area 2. On social media sites 3. At school during the day 4. On the ball field on weekends A growing practice has a marketing plan that addresses all these areas.

Point number one speaks to internal marketing. This is a learned skill for most practices, but the brothers, sisters, moms, dads, and friends of a patient who either come and sit in a practice’s reception area, or have a relationship of some kind with current patients, are all prospective new patients to a growing practice. Learning when and how to ask for a referral is usually an acquired skill.

The second area speaks to social media marketing execution. Social media sophistication is critical in today’s market in a growing practice. Having a website is only the starting point. Having a social media strategy that includes a YouTube channel, blog, SEO monitoring, backlinks from other sites, Facebook, Twitter, and LinkedIn are all parts of an overall social media strategy. The statistics on the percentage of parents (usually moms) that hit a practice’s website, read practice reviews, watch videos, read the practice’s blog prior to picking up the phone, and calling an office are staggering, some say upwards of 80%. Consultants can help, and so can younger employees, in making sure the social media presence is relevant, continually monitored and updated, and on point. Doing it right and carefully is extremely important, so consult with the experts for advice if this is not already part of a practice’s marketing plan. Practices that are growing are heavily leveraging a social media presence in speaking to the community and patients through various outlets.

Going to the ball field and being involved in the schools can be hard work, but a presence in the community is a common thread for growing practices.

Think beyond writing a check and more about participation to get the most mileage and interaction with potential patients when structuring strategies.

PRACTICE MANAGEMENT

to strategically prohibit a competitor from entering one’s drawing area and buy some revenue at the same time.

Merging two businesses requires a great deal of planning, and there are some considerations that must be taken into account in order to proceed with a given merger. Some of the major considerations are: • Culture: The two practitioners should be compatible with regards to service and practice philosophy.

• Death of a corporation: Typically one company dies, and the other lives. This means the benefit package of the dying corporation ends and is picked up by the buying corporation. Few staff members are satisfied with fewer benefits or lower pay. Analyzing the differences and “truing up” to make sure the staff has similar pay and benefits must be examined.

• Treatment philosophy: If the two companies are too divergent, the merger can be difficult as one prevalent treatment philosophy typically survives.

• Physical plant: If one location is going to close as a result of the merger, can the surviving facility adequately handle two doctors for a time and the influx of patients? If both locations are going to survive, due diligence on overhead effect is very important.

• Staffing: Do the staff from both offices survive the merger? Not always, and this can make for some difficult discussions and decisions.

• Fees: It is usually problematic to have two fee structures merge that are more than $1,000 apart. Think through how the two fee structures will be handled, and if a new fee for the new enterprise will be instituted.

Open a satellite Many practices have been in the same location for over 20 years. During that time,

60 Orthodontic practice

the community where many of the young families used to live may have moved.

Opening a satellite can be a good growth option.

There is a prevalent belief that adding a satellite will have a material negative effect on overhead causing an increase.

With several years of analysis, this does not appear to be true. In our practice valuations, we have noted: • A mature 1 day a week satellite typically produces $300-$400K in revenue.

• During 2011, practice overhead increased only 0.9% when comparing solo to multi-practices’ overhead. In 2010, the variance was 2.4%; in 2009 the variance was 0.7%; and in 2008, the variance was 0.8% (according to the Bentson Clark reSource’s annual practice survey data).

While it seems that many orthodontists believe that adding a practice location will result in a corresponding material rise in overhead, the data analyzed over the last several years would contradict that belief.

Certainly, complexity of practice life occurs when adding a satellite. Appropriate

demographic analysis and adhering to a budget for the buildout are important factors to consider when adding a satellite location.

Conclusion Growing practices must consider a number of options. We have reviewed some ideas that have been implemented in many growing practices. Several dozen or even hundreds of ideas can be added to this short list when discussing growing a practice. Be sure to focus on systems.

Remember that growth is a choice; it’s intentional. Growth takes an investment of time, money, and monitoring. Consultants can help in the growth process.

Practices are growing in all areas of the country, in all kinds of competitive environments. Why not make your practice the one that is growing in your drawing area? Good luck, and enjoy the process; the results are very rewarding.

Bentson Clark & Copple does not provide practice management consulting services.

OP

Visit www.orthopracticeus.com Email kmurphy@medmarkaz.com Call 1.866.579.9496

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Volume 4 Number 2

Against Decalcification

The Digital Orthodontist Jeff Johnson, DDS, MS Dallas, TX

Just words?

Over 10 independent University studies document these claims.

For our patients, suresmile is that tool which allows us to plan treatment with greater confidence and predictability than ever before.

In turn, this motivates patients to become partners in their treatment.

For a detailed case study, please call 888.672.6387 and request suresmile clinical report no. 1.

by Dr. Johnson

Pro Seal fluoride releasing enamel sealant.

Protection for all your patients.

www.suresmile.com Š2009 Reliance Orthodontic Products, Inc. All rights reserved.

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Orthodontic practice 63

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MATERIALS lllllllllllll & lllllllllllll EQUIPMENT Align Technology introduces the new iTero® imaging system for restorative or orthodontic procedures Align Technology, Inc. announced the new iTero imaging system available as a single hardware platform with software options for restorative or orthodontic procedures. iTero’s digitized workflow affords customers complete flexibility. Whether it’s a crown or bridge restoration, full or partial orthodontics (including Invisalign), an inlay/onlay, veneers, or a validated implant solution, doctors can select the option that best fits the needs of each individual case.

For more information on the new iTero scanning system, contact an iTero sales representative. To learn more about Invisalign or to find an Invisalign-trained doctor in your area, please visit www.Invisalign.com.

3Shape announces the official launch of its new TRIOS® Ortho solution 3Shape is now releasing a complete digital solution for orthodontic clinics that bundles the 3Shape TRIOS® digital impression solution with 3Shape’s Ortho Analyzer™ software. 3Shape TRIOS® Ortho provides intraoral scanning, clinical scan validation, and seamless communication with the orthodontic lab. The included 3Shape Ortho Analyzer™ software gives orthodontists tools for creating digital study models from the impression followed by advanced tools for treatment planning and case analysis.

For further information regarding 3Shape, please refer to www.3shapedental.com. Visit the company on www.facebook. com/3shape.

Easyrx launches its cloud-based prescription management software for orthodontists Easyrx® announced that it is releasing the next generation of digital prescription management for the orthodontic industry to practices and laboratories with its cloud-based software system.

The connection between the doctor and the lab has always been the prescription, and easyrx makes the process digital.

When a doctor or lab uses easyrx, they are able to experience a whole new concept of designing and managing prescriptions, and brings each of them one step closer to the paperless office.

EasyRx is a fully integrated, cloud-computing network enabling the clinician to create and view prescriptions with greater efficiency, manageability, and speed. With easyrx, all that’s needed is a computer and an Internet connection.

For more information and to learn more how doctors can receive a free 30-day trial, visit www.easyrxortho.com.

64 Orthodontic practice

Gendex introduces Scatter Reduction Technology (SRT™) to cone beam 3D Gendex has introduced SRT, Scatter Reduction Technology, to its award-winning GXDP-700™ Cone Beam 3D system. This new feature allows clinicians to reduce artifacts caused by metal or radio-opaque objects such as restorations, endodontic filling materials, and implant posts. The use of SRT image optimization technology delivers 3D scans with higher clarity and detail around scatter-generating material. SRT represents a significant aid when 3D scans are required for a variety of procedures from endodontic to restorative and the post-surgical assessment of implant sites. When a scan is prescribed near a known area of scattergenerating material, the user only needs to select the SRT button from the GXDP-700 touchscreen interface to utilize this new optimization technology.

For more information about the full line of Gendex products, visit www.gendex.com.

Align Technology announces availability of Invisalign® Outcome Simulator This intraoral scanning application helps patients visualize treatment benefits with Invisalign. The Invisalign Outcome Simulator is the company’s first Invisalign chairside application powered by the iTero and iOC scanners. Previewed earlier this year, the interactive application provides dentists and orthodontists with an enhanced platform for patient education and is designed to increase treatment acceptance by helping patients visualize the benefits possible of Invisalign treatment.

Using a full arch Invisalign scan, the easy-to-use Invisalign Outcome Simulator takes a few minutes to run and may be viewed chairside, on the scanner, or from a computer using MyAlignTech. com. Intuitive tools allow doctors to make real-time adjustments to individual teeth during consultations that increase patient education and the likelihood of patient acceptance.

For more information about the Invisalign Outcome Simulator, visit www.aligntechinstitute.com/simulator.

Focus Software announces the launch of Focus Ortho, cloud-based practice management software This software is designed to create the most accessible, organized, and efficient database possible while remaining simple to use for orthodontic staff. The streamlined interface allows offices to access patient data from a single screen. Treatment history, finances, notes, progress data, and more are all contained in dynamic sortable lists; creating a consistent interface that makes Focus Ortho extremely easy to use. The software features integrated email capabilities for patient communication and appointment reminders. The integrated web portal allows patients to fill out forms, confirm appointments, view their account history, and even pay bills online.

For additional information about Focus Ortho, visit www.FocusOrtho.com or call 888-247-6360.

Volume 4 Number 2